HIV-exposed infant follow-up in Mozambique: formative research findings for the design of a cluster randomized controlled trial to improve testing and ART initiation

Lúcia Vieira,Manuel Napua,Arlete Miloque Mahumane,Rachel R Chapman,James T Pfeiffer,Jessica Greenberg Cowan,Falume Chale,João Luís Manuel,Kenneth Sherr

doi:10.1186/s12913-020-5051-8

Abstract

BackgroundEarly infant diagnosis (EID) of HIV-exposed and initiation of HIV-positive infants on anti-retroviral therapy (ART) requires a well-coordinated cascade of care. Loss-to-follow-up (LTFU) can occur at multiple steps and effective EID is impeded by human resource constraints, difficulty with patient tracking, and long waiting periods. The objective of this research was to conduct formative research to guide the development of an intervention to improve the pediatric HIV care cascade in central Mozambique. The study was conducted in Manica and Sofala Provinces where the adult HIV burden is higher than the national average. The research focused on 3 large clinics in each province, along the highly populated Beira corridor.MethodsThe research was conducted in 2014 over 3 months at six facilities and consisted of 1) patient flow mapping and collection of health systems data from postpartum, child-at-risk, and ART service registries, 2) measurement of clinic waiting times, and 3) patient and health worker focus groups.ResultsHIV testing and ART initiation coverage for mothers tends to be high, but EID and pediatric ART initiation are hampered by lack of patient tracking, long waiting times, and inadequate counseling to navigate the care cascade. About 76% of HIV-positive infants were LTFU and did not initiate ART.ConclusionsEffective interventions to reduce LTFU in EID and improve pediatric ART initiation should focus on patient tracking, active follow-up of defaulting patients, reduction in EID turn-around times for PCR results, and initiation of ART by nurses in child-at-risk services.Trial registrationRetrospectively registered, ISRCTN67747315, July 24, 2019.

Highlights

Infant diagnosis (EID) of HIV-exposed and initiation of HIV-positive infants on anti-retroviral therapy (ART) requires a well-coordinated cascade of care
All are public facilities in the National Health Service that have provided the full range of PMTCT services, including HIV testing, access to CD4 testing (2 of 6 sites shipped the samples to a referral lab) and ART
The post-partum clinic visits and child-at-risk (CCR, consulta de criança em risco) clinic visits were staffed by mid-level maternal-child health (MCH) nurses, and ART for infants and children was provided by physician assistants, known as tecnicos de medicina, in Mozambique, and medical doctors

Summary

Introduction

Infant diagnosis (EID) of HIV-exposed and initiation of HIV-positive infants on anti-retroviral therapy (ART) requires a well-coordinated cascade of care. Diagnosis and care for children exposed to HIV remains a major challenge throughout the developing world [1,2,3]. The World Health Organization (WHO) estimated that by 2016 only 43% of HIV-exposed infants received an HIV test within the first 2 months of life, and by 2017 only 51% of HIV-positive children were receiving antiretroviral therapy (ART) [3]. HIV-positive infants should initiate lifelong ART [4], but in many settings they are not retained in care and never start treatment. The Children with HIV Early ART (CHER) trial in South Africa found a 76% reduction in mortality for infants started on ART before 3 months of age [8]. Without treatment, more than half of all HIV infected infants progress to AIDS and death by age two [8]

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