Integrating services works to curb HIV transmission from mothers to their infants and retain mothers in care, study shows

The following is a guest post by Emily Bobrow, PhD, of MEASURE Evaluation A combination of integrated service delivery approaches for mothers who are living with HIV has been shown in Uganda to improve retaining mothers in HIV care for 12 months and increasing exclusive breastfeeding for infants, as well as providing an increase in completed HIV test results for babies at 18 months of age. An outcome evaluation in Uganda, published this month in JAIDS, documented these results to have occurred at demonstration health facilities implementing the Partnership for HIV-Free Survival approach from 2013–2016. The goal of this outcome evaluation — conducted by MEASURE Evaluation, funded by USAID and the United States President’s Emergency Plan for AIDS Relief — was to assess whether, and to what degree, the Partnership implementation approach in Uganda improved prevention of mother-to-child transmission of HIV, improved data quality, and improved child health outcomes at the patient level. The full Partnership for HIV-Free Survival program implementation was carried out in six sub-Saharan countries -- Kenya, Lesotho, Mozambique, South Africa, Tanzania, and Uganda. Findings from the study suggested that the Partnership activities contributed to prevention of HIV transmission and, in turn to epidemic control. The study recommended the program should be sustained and scaled up and ought to be a priority for implementation throughout the region. The study further recommended that the approach should include integrated service delivery; training, coaching and mentoring for quality improvement methods; and stakeholder engagement. This evaluation gathered patient-level quantitative data from Partnership for HIV-Free Survival demonstration and scale-up health facilities, and from non-Partnership comparison facilities. The evaluation assessed individual outcomes, specifically exclusive breastfeeding, 12-month retention in care, 18-month mother-to-child HIV transmission, and 18-month HIV test data completeness. The evaluation measured the association of these individual outcomes and the sustainability of the approach after the program ended. Additionally, the evaluation gathered qualitative data from Partnership for HIV-Free Survival health facility staff and quality improvement coaches. Partnership implementation used a quality improvement approach to achieve its two program goals:  increased retention in care of HIV-positive mothers and their HIV-exposed children and optimized antiretroviral treatment coverage. The Partnership for HIV-Free Survival examined whether a combination of quality improvement activities could be introduced, implemented, and embraced by frontline staff to improve service delivery and outcomes. It was funded by PEPFAR through USAID in collaboration with the World Health Organization, UNICEF, and country health ministries. Further findings of MEASURE Evaluation’s study were that HIV transmission from mother to child had decreased at 18 months but that the lower rate was no different between demonstration sites and control groups. It found that after the program ended, increases in exclusive breast feeding and retention in care were sustained and data completeness continued to increase at demonstration sites. At scale-up facilities, however, while the partnership approach was associated with an increase in exclusive breast feeding, it showed no difference for retention in care, prevention of mother to child transmission, or data completeness. At scale-up sites after the program, the gains in exclusive breast feeding were lost and retention in care declined. The Partnership for HIV-Free Survival intervention was built on 2010 recommendations from WHO that governments address prevention of mother to child HIV transmission aims by providing antiretroviral therapy and exclusive breast feeding support to mothers living with HIV. The combination of antiretroviral treatment for the mother and exclusive breast feeding for the infant are known to decrease HIV transmission, to provide better nutrition for the infant, and reduce the chance of diarrheal disease as well. The Partnership for HIV-Free Survival program was begun because many high-burden countries in sub-Saharan Africa had found it difficult to operationalize these policies, particularly in the postpartum period.