The impact of adding community-based distribution of oral contraceptives and condoms to a cluster randomized primary health care intervention in rural Tanzania

Background Efforts to expand access to family planning in rural Africa often focus on the deployment of community health agents (CHAs). Methods This paper reports on results of the impact of a randomized cluster trial of CHA deployment on contraceptive uptake among 3078 baseline and 2551 endline women of reproductive age residing in 50 intervention and 51 comparison villages in Tanzania. Qualitative data were collected to broaden understanding of method preference, reasons for choice, and factors that explain non-use. Results Regression difference-in-differences results show that doorstep provision of oral contraceptive pills and condoms was associated with a null effect on modern contraceptive uptake [p = 0.822; CI 0.857; 1.229]. Discussions suggest that expanding geographic access without efforts to improve spousal and social support, respect preference for injectable contraceptives, and address perceived risk of side-effects offset the benefits of adopting contraceptives provided by community-based services. Conclusions The results of this study demonstrate that increasing access to services does not necessarily catalyze contraceptive use as method choice and spousal dynamics are key components of demand for contraception. Findings attest to the importance of strategies that respond to the climate of demand. Trial registration Controlled-Trial.com ISRCTN96819844. Retrospectively registered on 29.03.2012

Cost-Effectiveness of World Health Organization 2010 Guidelines for Prevention of Mother-to-Child HIV Transmission in Zimbabwe

Background. In 2010, the World Health Organization (WHO) released revised guidelines for prevention of mother-to-child human immunodeficiency virus (HIV) transmission (PMTCT). We projected clinical impacts, costs, and cost-effectiveness of WHO-recommended PMTCT strategies in Zimbabwe. Methods. We used Zimbabwean data in a validated computer model to simulate a cohort of pregnant, HIV-infected women (mean age, 24 years; mean CD4 count, 451 cells/µL; subsequent 18 months of breastfeeding). We simulated guideline-concordant care for 4 PMTCT regimens: single-dose nevirapine (sdNVP); WHO-recommended Option A, WHO-recommended Option B, and Option B+ (lifelong maternal 3-drug antiretroviral therapy regardless of CD4). Outcomes included maternal and infant life expectancy (LE) and lifetime healthcare costs (2008 US dollars [USD]). Incremental cost-effectiveness ratios (ICERs, in USD per year of life saved [YLS]) were calculated from combined (maternal + infant) discounted costs and LE. Results. Replacing sdNVP with Option A increased combined maternal and infant LE from 36.97 to 37.89 years and would reduce lifetime costs from $5760 to$5710 per mother–infant pair. Compared with Option A, Option B further improved LE (38.32 years), and saved money within 4 years after delivery ($5630 per mother–infant pair). Option B+ (LE, 39.04 years; lifetime cost,$6620 per mother–infant pair) improved maternal and infant health, with an ICER of $1370 per YLS compared with Option B. Conclusions. Replacing sdNVP with Option A or Option B will improve maternal and infant outcomes and save money; Option B increases health benefits and decreases costs compared with Option A. Option B+ further improves maternal outcomes, with an ICER (compared with Option B) similar to many current HIV-related healthcare interventions

What Will It Take to Eliminate Pediatric HIV? Reaching WHO Target Rates of Mother-to-Child HIV Transmission in Zimbabwe: A Model-Based Analysis

Using a simulation model, Andrea Ciaranello and colleagues find that the latest WHO PMTCT (prevention of mother to child transmission of HIV) guidelines plus better access to PMTCT programs, better retention of women in care, and better adherence to drugs are needed to eliminate pediatric HIV in Zimbabwe

Challenges Addressing Unmet Need for Contraception: Voices of Family Planning Service Providers in Rural Tanzania

Provider perspectives have been overlooked in efforts to address the challenges of unmet need for family planning (FP). This qualitative study was undertaken in Tanzania, using 22 key informant interviews and 4 focus group discussions. The research documents perceptions of healthcare managers and providers in a rural district on the barriers to meeting latent demand for contraception. Social-ecological theory is used to interpret the findings, illustrating how service capability is determined by the social, structural and organizational environment. Providers’ efforts to address unmet need for FP services are constrained by unstable reproductive preferences, low educational attainment, and misconceptions about contraceptive side effects. Societal and organizational factors – such as gender dynamics, economic conditions, religious and cultural norms, and supply chain bottlenecks, respectively – also contribute to an adverse environment for meeting needs for care. Challenges that healthcare providers face interact and produce an effect which hinders efforts to address unmet need. Interventions to address this are not sufficient unless the supply of services is combined with systems strengthening and social engagement strategies in a way that reflects the multi-layered, social institutional problems.Keywords: Contraception, Unmet need for family planning, Provider perspectives, Tanzania, Quality of car

Impact of uptake at key antenatal steps in the PMTCT cascade on MTCT at 4–6 wk of age.

<p>Results are shown with 56% uptake, sdNVP strategy. All data given as percents.</p

Results of a model of PMTCT services in Zimbabwe: cumulative 12-mo infant HIV infection risks.

<p>Results of a model of PMTCT services in Zimbabwe: cumulative 12-mo infant HIV infection risks.</p

Model input parameters: infant mortality.

<p>MOHCW, Zimbabwe Ministry of Health and Child Welfare.</p

PMTCT uptake scenarios.

a<p>Proportion of pregnant women accessing ANC, HIV testing for those in ANC, and receipt of HIV test result for those tested.</p>b<p>Proportion of ANC sites with access to medications for PMTCT. This proportion is back-calculated in order to reach the reported POP for each scenario.</p>c<p>Of women offered ARVs for PMTCT, the proportion remaining in care during the antenatal period, used as a proxy for acceptance of and adherence to medications. Retention in care postpartum: Of all postpartum women, the proportion linking to HIV care by the 6-wk postpartum visit. Impacts on MTCT of loss to follow-up after 6 wk postpartum, in the absence of specific data, are incorporated into highest-risk transmission estimates.</p>d<p>Proportion of patients receiving care at all stages of the PMTCT cascade, defined as the product of (drug availability)×(care and testing)×(retention).</p

Impact of availability of CD4 assays and ART for women with CD4≤350/µl.

a<p>Results highlight that providing CD4 assays for all women identified as HIV-infected, and ART for all women with CD4≤350/µl would lead to projected MTCT risks under the 2009 sdNVP-based program (56% uptake, sdNVP strategy: 11.4% at birth and 15.8% at 12 mo) comparable to if Option A were implemented at 56% uptake without increased CD4 and ART availability (56% uptake, Option A strategy: 12.0% at birth and 15.6% at 12 mo).</p

Key parameters determining MTCT risk.

<p>Tornado diagram summarizing the results of key one-way sensitivity analyses. Model parameters are on the vertical axis. For each parameter, the value used in the base-case analysis is listed in parentheses, followed by the range examined in sensitivity analysis. For example, the “regimen” provided for PMTCT is varied from Option B (lowest MTCT risk with all other parameters held constant), through Option A (base-case MTCT risk), to sdNVP (highest MTCT risk). The horizontal axis represents projected MTCT risk by the time of weaning. The solid vertical line represents transmission risk (14.4%) at the base-case set of parameters: 56% uptake, mean published MTCT risks, 36% of mothers with CD4<350/µl, breastfeeding duration of 12 mo, and the WHO “Option A” regimen. The dashed vertical line represents the 5% MTCT target of “virtual elimination” expressed by international HIV/AIDS agencies including WHO and the Joint United Nations Programme on HIV/AIDS. ARV prophylaxis in the Option A and Option B regimens is assumed to continue throughout the duration of breastfeeding.</p