title: Antiretroviral therapy in antenatal care to increase treatment initiation in HIV-infected pregnant women: a stepped-wedge evaluation.
abstract: BACKGROUND
  The objective of the study was to evaluate whether providing antiretroviral therapy (ART) integrated in antenatal care (ANC) clinics resulted in a greater proportion of treatment-eligible women initiating ART during pregnancy compared with the existing approach of referral to ART. ANALYSIS DESIGN AND METHODS: The evaluation used a stepped-wedge design and included all HIV-infected, ART-eligible pregnant women in eight public sector clinics in Lusaka district, Zambia. Main outcome indicators were the proportion of treatment-eligible pregnant women enrolling into HIV care within 60 days of HIV diagnosis, and of these, the proportion initiating ART during pregnancy. Adjusted odds ratios (AORs) and confidence intervals (CIs) for enrollment and initiation proportions were estimated through a logistic regression model accounting for clinical site cluster and time effects.
  
  
  RESULTS
  Between 16 July 2007 and 31 July 2008, 13,917 women started antenatal care more than 60 days before the intervention rollout and constituted the control cohort; 17 619 started antenatal care after ART integrated into ANC and constituted the intervention cohort. Of the 1566 patients found eligible for ART, a greater proportion enrolled while pregnant and within the 60 days of HIV diagnosis in the intervention cohort (376/846, 44.4%) compared with the control cohort (181/716, 25.3%), AOR 2.06, 95% CI (1.27-3.34); and initiated ART while pregnant in the intervention cohort (278/846, 32.9%) compared with the control cohort (103/716, 14.4%), AOR 2.01, 95% CI (1.37-2.95).
  
  
  CONCLUSIONS
  An integrated ART in ANC strategy doubled the proportion of treatment-eligible women initiating ART while pregnant.
authors.affiliation: Department of OB/GYN, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama 35294-0024, USA. wpkillam@gmail.com
authors.forename: William P
authors.initials: WP
authors.lastname: Killam
authors.forename: Bushimbwa C
authors.initials: BC
authors.lastname: Tambatamba
authors.forename: Namwinga
authors.initials: N
authors.lastname: Chintu
authors.forename: Dwight
authors.initials: D
authors.lastname: Rouse
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Stringer
authors.forename: Maximillian
authors.initials: M
authors.lastname: Bweupe
authors.forename: Yong
authors.initials: Y
authors.lastname: Yu
authors.forename: Jeffrey Sa
authors.initials: JS
authors.lastname: Stringer
mesh_terms: D000328:Adult; D018791:CD4 Lymphocyte Count; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000517:prevention & control / Q000635:transmission; D015497:HIV-1; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D010342:Patient Acceptance of Health Care / Q000523:psychology / Q000706:statistics & numerical data*; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy*; D011295:Prenatal Care; D011320:Primary Health Care; D015024:Zambia / Q000453:epidemiology