title: Addressing poor retention of infants exposed to HIV: a quality improvement study in rural Mozambique.
abstract: OBJECTIVE
  Early infant diagnosis (EID) is the first step in HIV care, yet 75% of HIV-exposed infants born at 2 hospitals in Mozambique failed to access EID.
  
  
  METHODS
  Before/after study.
  
  
  METHODS
  Two district hospitals in rural Mozambique.
  
  
  METHODS
  HIV-infected mother/HIV-exposed infant pairs (n = 791).
  
  
  METHODS
  We planned 2 phases of improvement using quality improvement methods. In phase 1, we enhanced referral by offering direct accompaniment of new mothers to the EID suite, increasing privacy, and opening a medical record for infants before postpartum discharge. In phase 2, we added enhanced referral activity as an item on the maternity register to standardize the process of referral.
  
  
  METHODS
  The proportion of HIV-infected mothers who accessed EID for their infant <90 days of life.
  
  
  RESULTS
  We tracked mother/infant pairs from June 2009 to March 2011 (phase 0: n = 144; phase 1: n = 479; phase 2: n = 168), compared study measures for mother/infant pairs across intervention phases with χ², estimated time-to-EID by Kaplan-Meier, and determined the likelihood of EID by Cox regression after adjusting for likely barriers to follow-up. At baseline (phase 0), 25.7% of infants accessed EID <90 days. EID improved to 32.2% after phase 1, but only 17.3% had received enhanced referral. After phase 2, 61.9% received enhanced referral and 39.9% accessed EID, a significant 3-phase improvement (P = 0.007). In adjusted analysis, the likelihood of EID at any time was higher in the phase 2 group versus phase 0 (adjusted hazard ratio: 1.68, 95% confidence interval: 1.19 to 2.37, P = 0.003).
  
  
  CONCLUSIONS
  Retention improved by 55% with a simple referral enhancement. Quality improvement efforts could help improve care in Mozambique and other low-resource countries [added].
authors.affiliation: Department of Pediatrics, Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, TN 37203, USA. philip.ciampa@vanderbilt.edu
authors.forename: Philip J
authors.initials: PJ
authors.lastname: Ciampa
authors.forename: José A
authors.initials: JA
authors.lastname: Tique
authors.forename: Nilton
authors.initials: N
authors.lastname: Jumá
authors.forename: Mohsin
authors.initials: M
authors.lastname: Sidat
authors.forename: Troy D
authors.initials: TD
authors.lastname: Moon
authors.forename: Russell L
authors.initials: RL
authors.lastname: Rothman
authors.forename: Sten H
authors.initials: SH
authors.lastname: Vermund
mesh_terms: D000328:Adult; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006298:Health Services Administration; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D055118:Medication Adherence; D009073:Mozambique; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011247:Pregnancy; D058996:Quality Improvement; D012424:Rural Population