Evaluating Implementation of revised (post 2010) World Health Organisation Guidelines on Prevention of Mother to Child Transmission of HIV using Routinely Collected Data in Zambia.

Abstract

The Joint United Nations Program on HIV/AIDS (UNAIDS) over the past two decades has documented the heavy burden and impact of HIV on mothers and infants living in resource-limited settings. The sub-Saharan Africa (SSA) region still faces a challenge of significant numbers of pregnant women who acquire HIV infection during pregnancy or postpartum but who are not diagnosed and offered antiretroviral medicines. The achievement of the UNAIDS goal relies on a successful implementation of a set of prevention of mother-to-child transmission (PMTCT) of HIV interventions called the PMTCT cascade. The goal of elimination of new paediatric infections has not been met, so there is a need to investigate why some programs are not effective. Routinely collected clinic data can provide much needed information on the prevalence of HIV among pregnant women and the uptake of services for PMTCT of HIV. In Zambia there is a substantial amount of data that has been collected through the SmartCare electronic health record system over the years, but the database has never been used to analyse the implementation of PMTCT programs. A mixed method study design was used which included a systematic review of literature, quantitative and qualitative methods. A systematic review of literature was conducted to identify, evaluate and summarise the findings from analysis of quantitative retrospective and prospective cohort studies that utilised routinely collected data with a focus on provision and utilisation of post 2010 PMTCT services in SSA. The quantitative analysis of SmartCare routinely collected data provided an overview of PMTCT coverage and the performance of early infant diagnosis (EID) services. Qualitative data was collected using in-depth interviews, observations and focus groups discussions (FGD) to understand the implementation procedures of SmartCare. The findings from the systematic review of literature showed a decrease in the mother to child transmission (MTCT) rate but poor quality routinely collected data. The quantitative analysis of 104, 155 pregnant women seeking antenatal care (ANC) services in 886 health facilities indicated an increase from 2010 to 2015 in the proportion of HIV- infected women who were already on treatment. The analysis of data comprising 32, 593 HIV-infected infants born in the pre (2006-2009) and post (2010-2016) Option B+ periods revealed that there has been progress in the EID program implementation. The results from the two quantitative studies were characterised by missing data which introduced bias and affected the external validity of the findings. The findings from SmartCare data analysis were triangulated with the Health Management Information System (HMIS), which further confirmed the conclusion drawn. The SmartCare database has structural challenges which can be traced to its development and in addition it has faced a lot of implementation challenges which include funding gaps, lack of feedback from the system and the absence of uniform data collection and verification procedures. The thesis is the first study to have attempted to evaluate the implementation of PMTCT guidelines using routinely collected data from the SmartCare electronic health record (EHR) system database. Recommendations arising from the thesis include upgrading of SmartCare into a networked Open Medical Record System. The Zambia MoH with its partners could also implement a SmartCare performance-based financing initiative in order to improve the implementation of EHR system. Further studies are needed to investigate the impact of implementing PMTCT guidelines particularly on the retention in care and adherence to treatment and EID.