Providing better care to HIV-infected pregnant women, children and their families in a rural sub-Saharan African clinic

Abstract

Novel strategies to increase the uptake of prevention of mother-to-child HIV transmission (PMTCT) services are needed in sub-Saharan Africa to reach the goal of elimination of paediatric HIV. In this same region, HIV diagnosis, linkage into care, antiretroviral treatment coverage and treatment outcomes of children need to be improved. Family-centered approaches may facilitate access to HIV care and improve the clinical management. This thesis was developed mainly as an operational and implementation science research. The main objective of this PhD was to improve maternal and paediatric HIV services in Ifakara, Tanzania, to move towards the UNAIDS goals: 1) elimination of paediatric HIV and 2) “90-90-90” target (i) 90% of children living with HIV know their HIV status, ii) 90% of children with diagnosed HIV receive ART, iii) 90% of children receiving ART are virologically suppressed). First, we conducted a cross-sectional study to assess the PMTCT services uptake in Ifakara. Second, we designed and implemented a package of measures as a strategy to improve the paediatric and maternal HIV care. Third, we evaluated the impact of the strategy. Forth, we did a prospective study evaluating the PMTCT cascade after the implementation of the package of measures and we compared the results with the initial cross-sectional assessment. Last, we investigated the prevalence and determinants of virological failure and acquired antiretroviral drug resistances in HIV-infected children. The studies included in this thesis show that with an operational approach, real changes can be implemented in a rural Tanzanian setting. The work in Ifakara documents a feasible and scalable model for maternal and paediatric HIV care that if extended to other sub-Saharan African settings can contribute to the goals of zero new HIV infections among children, keep mothers in good health and close the paediatric treatment gap.