Continuous quality improvement interventions to improve long-term outcomes of antiretroviral therapy in women who initiated therapy during pregnancy or breastfeeding in the Democratic Republic of Congo: design of an open-label, parallel, group randomized trial

Abstract Background Despite the rapid adoption of the World Health Organization’s 2013 guidelines, children continue to be infected with HIV perinatally because of sub-optimal adherence to the continuum of HIV care in maternal and child health (MCH) clinics. To achieve the UNAIDS goal of eliminating mother-to-child HIV transmission, multiple, adaptive interventions need to be implemented to improve adherence to the HIV continuum. Methods The aim of this open label, parallel, group randomized trial is to evaluate the effectiveness of Continuous Quality Improvement (CQI) interventions implemented at facility and health district levels to improve retention in care and virological suppression through 24 months postpartum among pregnant and breastfeeding women receiving ART in MCH clinics in Kinshasa, Democratic Republic of Congo. Prior to randomization, the current monitoring and evaluation system will be strengthened to enable collection of high quality individual patient-level data necessary for timely indicators production and program outcomes monitoring to inform CQI interventions. Following randomization, in health districts randomized to CQI, quality improvement (QI) teams will be established at the district level and at MCH clinics level. For 18 months, QI teams will be brought together quarterly to identify key bottlenecks in the care delivery system using data from the monitoring system, develop an action plan to address those bottlenecks, and implement the action plan at the level of their district or clinics. Discussion If proven to be effective, CQI as designed here, could be scaled up rapidly in resource-scarce settings to accelerate progress towards the goal of an AIDS free generation. Trial registration The protocol was retrospectively registered on February 7, 2017. ClinicalTrials.gov Identifier: NCT03048669

Exclusive Breastfeeding and Clinical Malaria Risk in 6-Month-Old Infants: A Cross-Sectional Study from Kinshasa, Democratic Republic of the Congo

The World Health Organization recommends exclusive breastfeeding (EBF) for the first 6 months of life. However, the effect of EBF on malaria risk remains unclear. In the present study, 137 EBF infants and 358 non-EBF infants from the Democratic Republic of the Congo were assessed for fever and malaria infections by polymerase chain reaction, at 6 months of age. EBF was associated with a reduced risk of clinical malaria (odds ratio = 0.13; 95% confidence interval = 0.00–0.80), suggesting a protective effect of EBF against malaria

Conditional Cash Transfers to Increase Retention in PMTCT Care, Antiretroviral Adherence, and Postpartum Virological Suppression: A Randomized Controlled Trial

Novel strategies are needed to increase retention in prevention of mother-to-child HIV transmission (PMTCT) services. We have recently shown that small, incremental cash transfers conditional on attending clinic resulted in increased retention along the PMTCT cascade. However, whether women who receive incentives to attend clinic visits are as adherent to antiretrovirals (ARV) as those who do not was unknown

Conditional Cash Transfers Improve Retention in PMTCT Services by Mitigating the Negative Effect of Not Having Money to Come to the Clinic

To elucidate the mechanisms by which a cash incentive intervention increases retention in prevention of mother-to-child transmission (PMTCT) services

Bed net ownership, use, and perceptions among women seeking antenatal care in Kinshasa, Democratic Republic of the Congo (DRC): opportunities for improved maternal and child health

Abstract: Background: To describe malaria knowledge, attitudes toward malaria and bed net use, levels of ownership and use of bed nets, and factors associated with ownership and use among pregnant women attending their first antenatal care (ANC) visit in Kinshasa, DRC. Methods: Women attending their first ANC visit at one maternity in Kinshasa were recruited to take part in a study where they were given free insecticide treated bed nets (ITNs) and then followed up at delivery and 6 months post delivery to assess ITN use. This study describes the baseline levels of bed net ownership and use, attitudes towards net use and factors associated with net use Results: Among 351 women interviewed at baseline, 115 (33%) already owned a bed net and 86 (25%) reported to have slept under the net the previous night. Cost was reported as the reason for not owning a net by 48% of the 236 women who did not own one. In multivariable analyses, women who had secondary school or higher education were 3.4 times more likely to own a net (95% CI 1.6–7.3) and 2.8 times more likely to have used a net (95% CI 1.3–6.0) compared to women with less education Conclusion: Distribution of ITNs in antenatal clinics in this setting is needed and feasible. The potential for ITN use by this target population is high

Low knowledge about hepatitis B prevention among pregnant women in Kinshasa, Democratic Republic of Congo

Infants infected perinatally with hepatitis B (HBV) are at the highest risk of developing chronic hepatitis and associated sequelae. Prevention of mother-to-child transmission (PMTCT) of HBV requires improved screening and awareness of the disease. This study evaluated existing HBV knowledge among pregnant mothers (n = 280) enrolled in two HBV studies in urban maternity centers in Kinshasa, Democratic Republic of the Congo. All mothers responded to three knowledge questions upon study enrollment. Baseline levels of knowledge related to HBV transmission, treatment, prevention, and symptoms were low across all participants: 68.8% did not know how HBV was transmitted, 70.7% did not know how to prevent or treat HBV MTCT, and 79.6% did not know signs and symptoms of HBV. Over half of participants responded “I don’t know” to all questions. HBV-positive women who participated in both studies (n = 46) were asked the same questions during both studies and showed improved knowledge after screening and treatment, despite no formal educational component in either study (p < 0.001). These findings highlight the need for intensified education initiatives in highly endemic areas to improve PMTCT efforts

Bed net ownership, use and perceptions among women seeking antenatal care in Kinshasa, Democratic Republic of the Congo (DRC): Opportunities for improved maternal and child health

Abstract: Background: To describe malaria knowledge, attitudes toward malaria and bed net use, levels of ownership and use of bed nets, and factors associated with ownership and use among pregnant women attending their first antenatal care (ANC) visit in Kinshasa, DRC. Methods: Women attending their first ANC visit at one maternity in Kinshasa were recruited to take part in a study where they were given free insecticide treated bed nets (ITNs) and then followed up at delivery and 6 months post delivery to assess ITN use. This study describes the baseline levels of bed net ownership and use, attitudes towards net use and factors associated with net use Results: Among 351 women interviewed at baseline, 115 (33%) already owned a bed net and 86 (25%) reported to have slept under the net the previous night. Cost was reported as the reason for not owning a net by 48% of the 236 women who did not own one. In multivariable analyses, women who had secondary school or higher education were 3.4 times more likely to own a net (95% CI 1.6–7.3) and 2.8 times more likely to have used a net (95% CI 1.3–6.0) compared to women with less education Conclusion: Distribution of ITNs in antenatal clinics in this setting is needed and feasible. The potential for ITN use by this target population is high

Continuous quality improvement interventions to improve long-term outcomes of antiretroviral therapy in women who initiated therapy during pregnancy or breastfeeding in the Democratic Republic of Congo: design of an open-label, parallel, group randomized trial

Abstract Background Despite the rapid adoption of the World Health Organization’s 2013 guidelines, children continue to be infected with HIV perinatally because of sub-optimal adherence to the continuum of HIV care in maternal and child health (MCH) clinics. To achieve the UNAIDS goal of eliminating mother-to-child HIV transmission, multiple, adaptive interventions need to be implemented to improve adherence to the HIV continuum. Methods The aim of this open label, parallel, group randomized trial is to evaluate the effectiveness of Continuous Quality Improvement (CQI) interventions implemented at facility and health district levels to improve retention in care and virological suppression through 24 months postpartum among pregnant and breastfeeding women receiving ART in MCH clinics in Kinshasa, Democratic Republic of Congo. Prior to randomization, the current monitoring and evaluation system will be strengthened to enable collection of high quality individual patient-level data necessary for timely indicators production and program outcomes monitoring to inform CQI interventions. Following randomization, in health districts randomized to CQI, quality improvement (QI) teams will be established at the district level and at MCH clinics level. For 18 months, QI teams will be brought together quarterly to identify key bottlenecks in the care delivery system using data from the monitoring system, develop an action plan to address those bottlenecks, and implement the action plan at the level of their district or clinics. Discussion If proven to be effective, CQI as designed here, could be scaled up rapidly in resource-scarce settings to accelerate progress towards the goal of an AIDS free generation. Trial registration The protocol was retrospectively registered on February 7, 2017. ClinicalTrials.gov Identifier: NCT03048669

Impact of WHO 2010 Guidelines on Antiretroviral Therapy Initiation among Patients with HIV-Associated Tuberculosis in Clinics with and without Onsite HIV Services in the Democratic Republic of Congo

Background. We assessed the impact of WHO&apos;s 2010 guidelines that removed the requirement of CD4 count before ART, on timely initiation of ART among HIV/TB patients in the Democratic Republic of Congo (DRC). Methods. Data collected to monitor implementation of provider initiated HIV testing and counseling (PITC) and linkage to HIV care from 65 and 13 TB clinics in Kinshasa and Kisangani, respectively, between November 2010 and June 2013. Results. Prior to the WHO&apos;s 2010 guidelines, in Kinshasa, 79.1% (401/507) of HIV/TB patients referred for HIV services were initiated on ART in clinics with onsite ART services compared to 50.0% (63/123) in clinics without. Following the implementation of the new guidelines, 89.8% (714/795) and 93.0% (345/371) of HIV/TB patients referred for HIV services were initiated on ART, respectively, in clinics with onsite and without onsite ART services. Similarly, in Kisangani, 69.7% (53/120) and 36.4% (16/44) in clinics with and without onsite ART service, respectively, were initiated on ART prior to the 2010 guidelines and 88.8% (135/152) and 72.6% (106/146), respectively, after the new guidelines. Conclusion. Though implementation of the 2010 guidelines increased the proportion of HIV/TB patients initiated on ART substantially, it remained below the 100% target, particularly in clinics without onsite ART services