Factors associated with access to HIV care and treatment in a prevention of mother to child transmission programme in urban Zimbabwe

<p>Abstract</p> <p>Background</p> <p>This cross-sectional study assessed factors affecting access to antiretroviral therapy (ART) among HIV-positive women from the prevention of mother to child transmission HIV programme in Chitungwiza, Zimbabwe.</p> <p>Methods</p> <p>Data were collected between June and August 2008. HIV-positive women attending antenatal clinics who had been referred to the national ART programme from January 2006 until December 2007 were surveyed. The questionnaire collected socio-demographic data, treatment-seeking behaviours, and positive or negative factors that affect access to HIV care and treatment.</p> <p>Results</p> <p>Of the 147 HIV-positive women interviewed, 95 (65%) had registered with the ART programme. However, documentation of the referral was noted in only 23 (16%) of cases. Of the 95 registered women, 35 (37%) were receiving ART; 17 (18%) had not undergone CD4 testing. Multivariate analysis revealed that participants who understood the referral process were three times more likely to access HIV care and treatment (OR = 3.21, 95% CI 1.89-11.65) and participants enrolled in an HIV support group were twice as likely to access care and treatment (OR = 2.34, 95% CI 1.13-4.88). Those living with a male partner were 60% less likely to access care and treatment (OR = 0.40, 95% CI 0.16-0.99). Participants who accessed HIV care and treatment faced several challenges, including long waiting times (46%), unreliable access to laboratory testing (35%) and high transport costs (12%). Of the 147 clients surveyed, 52 (35%) women did not access HIV care and treatment. Barriers included perceived long queues (50%), competing life priorities, such as seeking food or shelter (33%) and inadequate referral information (15%).</p> <p>Conclusions</p> <p>Despite many challenges, the majority of participants accessed HIV care. Development of referral tools and decentralization of CD4 testing to clinics will improve access to ART. Psychosocial support can be a successful entry point to encourage client referral to care and treatment programmes.</p

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

WHO 2010 Guidelines for Prevention of Mother-to-Child HIV Transmission in Zimbabwe: Modeling Clinical Outcomes in Infants and Mothers

The Zimbabwean national prevention of mother-to-child HIV transmission (PMTCT) program provided primarily single-dose nevirapine (sdNVP) from 2002-2009 and is currently replacing sdNVP with more effective antiretroviral (ARV) regimens.Published HIV and PMTCT models, with local trial and programmatic data, were used to simulate a cohort of HIV-infected, pregnant/breastfeeding women in Zimbabwe (mean age 24.0 years, mean CD4 451 cells/µL). We compared five PMTCT regimens at a fixed level of PMTCT medication uptake: 1) no antenatal ARVs (comparator); 2) sdNVP; 3) WHO 2010 guidelines using "Option A" (zidovudine during pregnancy/infant NVP during breastfeeding for women without advanced HIV disease; lifelong 3-drug antiretroviral therapy (ART) for women with advanced disease); 4) WHO "Option B" (ART during pregnancy/breastfeeding without advanced disease; lifelong ART with advanced disease); and 5) "Option B+:" lifelong ART for all pregnant/breastfeeding, HIV-infected women. Pediatric (4-6 week and 18-month infection risk, 2-year survival) and maternal (2- and 5-year survival, life expectancy from delivery) outcomes were projected.Eighteen-month pediatric infection risks ranged from 25.8% (no antenatal ARVs) to 10.9% (Options B/B+). Although maternal short-term outcomes (2- and 5-year survival) varied only slightly by regimen, maternal life expectancy was reduced after receipt of sdNVP (13.8 years) or Option B (13.9 years) compared to no antenatal ARVs (14.0 years), Option A (14.0 years), or Option B+ (14.5 years).Replacement of sdNVP with currently recommended regimens for PMTCT (WHO Options A, B, or B+) is necessary to reduce infant HIV infection risk in Zimbabwe. The planned transition to Option A may also improve both pediatric and maternal outcomes

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

What Works for Health Systems Strengthening: An Overview of the Evidence – Resource Toolkit

This resource toolkit has been produced by K4D in partnership with the Health Systems Team in the Foreign, Commonwealth & Development Office (FCDO) Human Development Department and renowned global health systems expert Prof. Sophie Witter (Queen Margaret University, Edinburgh). The toolkit is aimed at FCDO’s network of health advisors, and policy and programme managers based in country offices and central teams. The purpose of this toolkit is to summarise and present key messages from the latest evidence on ‘what works’ for health systems strengthening (HSS) to help embed a stronger HSS approach into all of our work on health as outlined in FCDO’s position paper Health Systems Strengthening for Global Health Security and Universal Health Coverage (FCDO 2021). The toolkit draws extensively on more detailed pieces of work analysing the evidence in more depth, which were disseminated through the health network in FCDO (and previously the Department for International Development) between 2019 and 2022 titled Evidence Review of What Works for Health Systems Strengthening, Where and When? (Witter et al. 2021). This toolkit also links back to a multitude of resources and recorded sessions collected as part of K4Ds previous learning journey on HSS.Accompanying and supporting this guide is an illustration that explores what works for health systems strengthening. It summarises key elements and processes that can be used by programmes.Foreign, Commonwealth and Development Office (FCDO

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 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

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