title: Lesotho's minimum PMTCT package: lessons learned for combating vertical HIV transmission using co-packaged medicines.
abstract: BACKGROUND
  Mother-to-child transmission of HIV can be reduced to<5% with appropriate antiretroviral medications. Such reductions depend on multiple health system encounters during antenatal care (ANC), delivery and breastfeeding; in countries with limited access to care, transmission remains high. In Lesotho, where 28% of women attending ANC are HIV positive but where geographic and other factors limit access to ANC and facility deliveries, a Minimum PMTCT Package was launched in 2007 as an alternative to the existing facility-based approach. Distributed at the first ANC visit, it packaged together all necessary pregnancy, delivery and early postnatal antiretroviral medications for mother and infant.
  
  
  METHODS
  To examine the availability, feasibility, acceptability and possible negative consequences of the Minimum PMTCT Package, data from a 2009 qualitative and quantitative study and a 2010 facility assessment were used. To examine the effects on ANC and facility-based delivery rates, a difference-in-differences analytic approach was applied to 2009 Demographic and Health Survey data for HIV-tested women who gave birth before and after Minimum PMTCT Package implementation.
  
  
  RESULTS
  The Minimum PMTCT Package was feasible and acceptable to providers and clients. Problems with test kit and medicine stock-outs occurred, and 46% of women did not receive the Minimum PMTCT Package until at least their second ANC visit. Providing adequate instruction on the use of multiple medications represented a challenge. The proportion of HIV-positive women delivering in facilities declined after Minimum PMTCT Package implementation, although it increased among HIV-negative women (difference-in-differences=14.5%, p=0.05). The mean number of ANC visits declined more among HIV-positive women than among HIV-negative women after implementation, though the difference was not statistically significant (p=0.09). Changes in the percentage of women receiving≥4 ANC visits did not differ between the two groups.
  
  
  CONCLUSIONS
  If supply issues can be resolved and adequate client educational materials provided, take-away co-packages have the potential to increase access to PMTCT commodities in countries where women have limited access to health services. However, efforts must be made to carefully monitor potential changes in ANC visits and facility deliveries, and further evaluation of adherence, safety and effectiveness are needed.
authors.affiliation: Joint Doctoral Program in Public Health (Global Health), San Diego State University/University of California, San Diego, USA.
authors.forename: Lotus
authors.initials: L
authors.lastname: McDougal
authors.forename: Mpolai M
authors.initials: MM
authors.lastname: Moteetee
authors.forename: Florence
authors.initials: F
authors.lastname: Mohai
authors.forename: Malisebo
authors.initials: M
authors.lastname: Mphale
authors.forename: Binod
authors.initials: B
authors.lastname: Mahanty
authors.forename: Blandinah
authors.initials: B
authors.lastname: Motaung
authors.forename: Victor
authors.initials: V
authors.lastname: Ankrah
authors.forename: Makaria
authors.initials: M
authors.lastname: Reynolds
authors.forename: Kenneth
authors.initials: K
authors.lastname: Legins
authors.forename: Appolinaire
authors.initials: A
authors.lastname: Tiam
authors.forename: Chewe
authors.initials: C
authors.lastname: Luo
authors.forename: Craig
authors.initials: C
authors.lastname: McClure
authors.forename: Nancy
authors.initials: N
authors.lastname: Binkin
mesh_terms: D019380:Anti-HIV Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D004349:Drug Packaging; D005240:Feasibility Studies; D005260:Female; D015658:HIV Infections / Q000453:epidemiology / Q000517:prevention & control* / Q000635:transmission*; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D007927:Lesotho / Q000453:epidemiology; D011247:Pregnancy; D011295:Prenatal Care / Q000706:statistics & numerical data
chemical_list: D019380:Anti-HIV Agents