Abstract
IntroductionHigh retention in care is paramount to reduce vertical human immunodeficiency virus (HIV) infections in prevention of mother-to-child transmission (PMTCT) programmes but remains low in many sub-Saharan African countries. We aimed to assess the effects of community health worker–based defaulter tracing (CHW-DT) on retention in care and mother-to-child HIV transmission, an innovative approach that has not been evaluated to date.MethodsWe analyzed patient records of 1878 HIV-positive pregnant women and their newborns in a rural PMTCT programme in the Tsholotsho district of Zimbabwe between 2010 and 2013 in a retrospective cohort study. Using binomial regression, we compared vertical HIV transmission rates at six weeks post-partum, and retention rates during the perinatal PMTCT period (at delivery, nevirapine [NVP] initiation at three days post-partum, cotrimoxazole (CTX) initiation at six weeks post-partum, and HIV testing at six weeks post-partum) before and after the introduction of CHW-DT in the project.ResultsMedian maternal age was 27 years (inter-quartile range [IQR] 23 to 32) and median CD4 count was 394 cells/µL3 (IQR 257 to 563). The covariate-adjusted rate ratio (aRR) for perinatal HIV transmission was 0.72 (95% confidence intervals [95% CI] 0.27 to 1.96, p=0.504), comparing patient outcomes after and before the intervention. Among fully retained patients, 11 (1.9%) newborns tested HIV positive. ARRs for retention in care were 1.01 (95% CI 0.96 to 1.06, p=0.730) at delivery; 1.35 (95% CI 1.28 to 1.42, p<0.001) at NVP initiation; 1.78 (95% CI 1.58 to 2.01, p<0.001) at CTX initiation; and 2.54 (95% CI 2.20 to 2.93, p<0.001) at infant HIV testing. Cumulative retention after and before the intervention was 496 (85.7%) and 1083 (87.3%) until delivery; 480 (82.9%) and 1005 (81.0%) until NVP initiation; 303 (52.3%) and 517 (41.7%) until CTX initiation; 272 (47.0%) and 427 (34.4%) until infant HIV testing; and 172 (29.7%) and 405 (32.6%) until HIV test result collection.ConclusionsThe CHW-DT intervention did not reduce perinatal HIV transmission significantly. Retention improved moderately during the post-natal period, but cumulative retention decreased rapidly even after the intervention. We showed that transmission in resource-limited settings can be as low as in resource-rich countries if patients are fully retained in care. This requires structural changes to the regular PMTCT services, in which community health workers can, at best, play a complementary role.
Highlights
High retention in care is paramount to reduce vertical human immunodeficiency virus (HIV) infections in prevention of mother-to-child transmission (PMTCT) programmes but remains low in many sub-Saharan African countries
After adjusting for cluster of differentiation Type 4 lymphocyte (CD4) cell count, World Health Organization (WHO) clinical stage, age, ARV regimen and treatment area, retention at each cascade step separately irrespective of successful retention at previous steps after community health workerÁbased defaulter tracing (CHW-DT) introduction in April 2012 compared with retention before that date was 85.7 and 84.3% at delivery; 96.6 and 92.0% at infant NVP initiation; 62.0 and 49.1% at infant CTX initiation; and 94.7 and 73.7% at infant HIV testing (Table 2)
Association between the introduction of Community health workers (CHWs)-DT in April 2012 and retention in care among HIV-positive pregnant women and their newborns irrespective of completeness of retention at previous steps, enrolled into the MSF Tsholotsho PMTCT programme between February 2010 and March 2013. adjusted rate ratio (aRR): adjusted risk ratio; ARV: antiretroviral; CD4: cluster of differentiation Type 4 lymphocyte; CHW-DT: community health workerÁ based defaulter tracing; cRR: crude risk ratio; CTX: cotrimoxazole; IQR: inter-quartile range; MSF: Medecins Sans Frontieres; N: number of patients; NVP: nevirapine; PMTCT: prevention of mother-to-child transmission; 95% confidence intervals (95% CI): 95% confidence interval
Summary
High retention in care is paramount to reduce vertical human immunodeficiency virus (HIV) infections in prevention of mother-to-child transmission (PMTCT) programmes but remains low in many sub-Saharan African countries. Prevention of mother-to-child transmission (PMTCT) programmes have become part of many HIV programmes in subSaharan Africa (SSA) [1,7,12Á16] In most of these settings, HIV-positive pregnant women who meet the ART eligibility criteria based on cluster of differentiation Type 4 lymphocyte (CD4) cell count and World Health Organization (WHO) clinical staging receive lifelong ART. For those women not eligible for treatment, WHO recommended until recently two prophylactic options: Option A or Option B [17,18]. Due to the high risk for opportunistic infections, WHO recommends cotrimoxazole (CTX) prophylaxis to prevent Pneumocystis carinii pneumonia for all infants of HIV-positive mothers starting at six weeks post-partum [21Á23]
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