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. 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.
We 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.
Median maternal age was 27 years (inter-quartile range [IQR]
23 to 32) and median CD4 count was 394 cells/µL(3) (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.
The 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.
Below: Cumulative retention before and after the intervention. Cumulative retention in care along the PMTCT cascade among HIV-positive pregnant women and their newborns with complete retention at all previous steps, enrolled before and after the introduction of CHW-DT in April 2012 into the MSF Tsholotsho PMTCT programme between February 2010 and March 2013. CHW-DT: community health worker–based defaulter tracing; CTX: cotrimoxazole; HIV: human immunodeficiency virus; MSF: Médecins Sans Frontières; NVP: nevirapine; PMTCT: prevention of mother-to-child transmission.
Full article
at:
By:
- 1Operational Centre Barcelona, Médecins Sans Frontières/Doctors Without Borders, Barcelona, Spain; florianvogt@hotmail.com.
- 2Operational Centre Barcelona, Médecins Sans Frontières/Doctors Without Borders, Barcelona, Spain.
- 3Tsholotsho Project, Médecins Sans Frontières/Doctors Without Borders, Tsholotsho, Zimbabwe.
- 4Zimbabwe Mission, Médecins Sans Frontières/Doctors Without Borders, Harare, Zimbabwe.
- 5Tsholotsho District Medical Office, Ministry of Health and Child Welfare, Tsholotsho, Zimbabwe.
- 6Department of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
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