This RRI was implemented to address key PMTCT service challenges and to specifically increase uptake of HAART in HIV-positive pregnant women and infants. The RRI was associated with a 13% increase in assessment for HAART eligibility via improved CD4 testing, which translated to 66.6% of HIV positive pregnant women getting CD4 testing. CD4 testing uptake was sustained in the post-RRI period. More encouraging was uptake of HAART for pregnant women, which increased during the RRI by 44% from baseline and by 58% post-RRI, showing an increased capacity for HAART uptake. By improving HAART uptake, facilities are closer to reaching the 30% of expected eligible HIV-positive women. Improved clinical staging likely also contributed to increased HAART uptake however, government data collection tools used during the intervention did not document clinical staging making it difficult to determine its contribution. Due to the cohort nature of this evaluation, it is not possible to determine the eligibility of each individual woman; however it is clear that despite substantial progress in HAART initiation, many are still not accessing this critical service since uptake still lags below 30%. Reasons likely include incomplete assessment for eligibility, failure to return to the ANC clinic for CD4 results and HAART initiation (despite tracing efforts and counseling), and lack of availability of HAART services at smaller health facilities resulting in unsuccessful linkage to a health facility providing full HIV services including HAART.
Early infant diagnosis via PCR testing is a key step in increasing uptake of HAART for HIV-infected infants. The RRI was associated with a 30% increase in PCR testing from baseline, which further improved by 90% from baseline compared in the post-RRI period. Additionally, review of many facility records showed a faster turnaround time for PCR testing (data not shown). Along with improved identification of HAART-eligible infants, actual HAART uptake increased modestly 1.1-fold during the RRI but 1.3-fold in the post-RRI period. Similar to HAART uptake amongst HIV-positive pregnant women, uptake of HAART in HIV-positive infants remained a challenge despite RRI efforts. Further evaluation of barriers to HAART uptake should be reviewed and best practices implemented.
Male involvement as measured by partner HIV testing also significantly increased during the intervention. Male partner HIV testing increased 2.1-fold during the RRI and was sustained at 50% increased level of testing in the post-RRI period. However, the absolute percentage of women attending ANC whose partner came for HIV testing remained low (<20%). We believe this is an essential component to PMTCT service uptake and retention. Women who fail to disclose to their partners due to fear, stigma, or denial are much more likely to default care, and less likely to deliver in a health facility [14
]. HIV couples counseling and testing provide a facilitated environment for HIV testing where issues of blame, discordance, and future care options are explained [14
We believe community mobilization as well as leadership and involvement of the MOH, though difficult to measure, contributed significantly to success of the RRI. Ultimately, health-seeking behavior is determined at an individual level but heavily influenced by family and community attitudes and behaviors. The use of opinion leaders such as chiefs, district administration, peer educators, and community health workers likely sensitized the community to the importance of PMTCT services. Which particular activities within community mobilization are most effective in changing attitudes, and behavior is a key research topic for future evaluations. Given the setting of the RRI primarily within government health facilities in rural communities and the need to build sustainable and lasting interventions, it was essential to have MOH ownership and leadership for this intervention.
Strengths of this study include its applicability and reproducibility in other PMTCT programs. Governments, nongovernmental organizations (NGOs), and other partners implementing PMTCT services can adapt the RRI concept to their particular settings and assess its impact. Weaknesses include difficulty in assessing the impact of particular strategies including community mobilization and male partner involvement. Additionally, this was a nonrandomized intervention. Community and facility level confounders cannot be ruled out. Furthermore, data were collected by facilities and technical staff supporting those facilities that had an interest in seeing improvements based on their work. Routine data quality audits were conducted at a portion of sites by an independent team, the monitoring and evaluation officers.
The ultimate goal of PMTCT programs is to provide high quality, cost-effective services that translate into saved lives and reduced morbidity among women and children. While the RRI concept focuses on intensive intervention over a short period, the program was designed to use strategies that build healthcare worker capacity and strengthen overall systems such as laboratory networking that lead to sustained improvements in outcomes. While we found that the RRI was associated with a relatively short-term sustained improvement in most indicators, further research is required to determine its longer term impact, the need for repeat RRIs, and newer evidence-based practices such as ANC and HIV care and treatment service integration. The followup phase of the RRI is ongoing and includes routine support of implementation of PMTCT services, which includes support supervision, mentorship, technical support, and CQI activities. A truly integrated multidisciplinary approach which engages key stakeholders including the local community, such that promoted during the RRI, will play an important role towards reaching the goal of eliminating mother-to-child transmission of HIV and improving health outcomes for HIV-positive women.