title: Ensuring HIV-infected pregnant women start antiretroviral treatment: an operational cohort study from Lilongwe, Malawi.
abstract: OBJECTIVE
  HIV-infected women identified through antenatal care (ANC) often fail to access antiretroviral treatment (ART), leaving them and their infants at risk for declining health or HIV transmission. We describe results of measures to improve uptake of ART among eligible pregnant women.
  
  
  METHODS
  Between October 2006 and December 2009, interventions implemented at ANC and ART facilities in urban Lilongwe aimed to better link services for women with CD4 counts <250/μl. A monitoring system followed women referred for ART to examine trends and improve practices in referral completion, on-time ART initiation and ART retention.
  
  
  RESULTS
  Six hundred and twelve women were ART eligible: 604 (99%) received their CD4 result, 344 (56%) reached the clinic, 286 (47%) started ART while pregnant and 261 (43%) were either alive on ART or transferred out after 6 months. Between 2006 and 2009, the median (IQR) time between CD4 blood draw and ART initiation fell from 41 days (17, 349) to 15 days (7,42) (P = 0.183); the proportion of eligible individuals starting ART while pregnant and retained for 6 months improved from 17% to 65% (P < 0.001). Delays generally shortened within the continuum of care from 2006 to 2009; however, time from CD4 blood draw to ART referral increased from 7 to 14 days.
  
  
  CONCLUSIONS
  Referrals between facilities and delays through CD4 count measurements create bottlenecks in patient care. Retention improved over time, but delays within the linkage process remained. ART initiation at ANC plus use of point-of-care CD4 tests may further enhance ART uptake.
authors.affiliation: Lighthouse Trust at Kamuzu Central Hospital, Lilongwe, Malawi. ralf.weigel@liverpool.ac.uk
authors.forename: Ralf
authors.initials: R
authors.lastname: Weigel
authors.forename: Mina C
authors.initials: MC
authors.lastname: Hosseinipour
authors.forename: Caryl
authors.initials: C
authors.lastname: Feldacker
authors.forename: Dickman
authors.initials: D
authors.lastname: Gareta
authors.forename: Hannock
authors.initials: H
authors.lastname: Tweya
authors.forename: Jane
authors.initials: J
authors.lastname: Chiwoko
authors.forename: Joe
authors.initials: J
authors.lastname: Gumulira
authors.forename: Mike
authors.initials: M
authors.lastname: Kalulu
authors.forename: Innocent
authors.initials: I
authors.lastname: Mofolo
authors.forename: Esmie
authors.initials: E
authors.lastname: Kamanga
authors.forename: Gertrude
authors.initials: G
authors.lastname: Mwale
authors.forename: Angela
authors.initials: A
authors.lastname: Kadzakumanja
authors.forename: Edward
authors.initials: E
authors.lastname: Jere
authors.forename: Sam
authors.initials: S
authors.lastname: Phiri
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D003266:Continuity of Patient Care / Q000458:organization & administration; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000635:transmission; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008295:Malawi; D019095:Point-of-Care Systems; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy* / Q000276:immunology; D011295:Prenatal Care / Q000379:methods*; D012017:Referral and Consultation / Q000458:organization & administration*; D014505:Urban Population / Q000706:statistics & numerical data; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents