title: Implementation and Operational Research: Barriers and Facilitators to Combined ART Initiation in Pregnant Women With HIV: Lessons Learnt From a PMTCT B+ Pilot Program in Swaziland.
abstract: BACKGROUND
  In January 2013, Swaziland launched a prevention of mother-to-child transmission of HIV (PMTCT) B+ implementation study in rural Shiselweni. We aimed to identify patient and health service determinants of combined antiretroviral therapy (ART) initiation to help guide national implementation of PMTCT B+.
  
  
  METHODS
  This prospective cohort study uses routine data from registers and patient files in the PMTCT B+ pilot zone and a neighboring health zone where PMTCT A was the standard of care. All HIV-positive women not on combined ART at the first antenatal care visit between January 28, 2013 and December 31, 2013 were included.
  
  
  RESULTS
  399 women from the PMTCT B+ zone and 183 from the PMTCT A zone are included. The overall proportion of women who had not started an antiretroviral intervention before 32 weeks' gestation was lower in the PMTCT A zone (13% vs 25%, P = 0.003), yet a higher proportion women with CD4 <350 initiated combined ART in the PMTCT B+ zone (86% vs 74%, P = 0.032). Within the PMTCT B+ pilot, initiation rates were highly variable between health facilities; while at patient level, ART initiation was significantly higher among women with CD4 <350 compared with CD4 >350 (80% vs 59%, P < 0.001). Among women with CD4 <350, those recorded as newly diagnosed were more likely to initiate combined ART. Although lower educational level and occupational barriers seemed to hinder combined ART initiation among women with CD4 >350, high proportions of missing socio-demographic data made it impossible to make any firm conclusions to this respect.
  
  
  CONCLUSIONS
  This study not only demonstrates challenges in initiating pregnant women on ART, but also identifies opportunities offered by PMTCT B+ for improving treatment initiation among women with lower CD4 counts.
authors.affiliation: *Médecins sans Frontières, Geneva, Switzerland; †Swaziland National AIDS Programme, Mbabane, Swaziland; ‡Médecins sans Frontières, Nhlangano, Swaziland; and §Médecins sans Frontières, Mbabane, Swaziland.
authors.forename: Lucy A
authors.initials: LA
authors.lastname: Parker
authors.forename: Kiran
authors.initials: K
authors.lastname: Jobanputra
authors.forename: Velephi
authors.initials: V
authors.lastname: Okello
authors.forename: Mpumelelo
authors.initials: M
authors.lastname: Nhlangamandla
authors.forename: Sikhathele
authors.initials: S
authors.lastname: Mazibuko
authors.forename: Tatiana
authors.initials: T
authors.lastname: Kourline
authors.forename: Bernhard
authors.initials: B
authors.lastname: Kerschberger
authors.forename: Elias
authors.initials: E
authors.lastname: Pavlopoulos
authors.forename: Roger
authors.initials: R
authors.lastname: Teck
mesh_terms: D000293:Adolescent; D000328:Adult; D044966:Anti-Retroviral Agents / Q000008:administration & dosage*; D023241:Antiretroviral Therapy, Highly Active; D015331:Cohort Studies; D013541:Eswatini; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000517:prevention & control / Q000635:transmission; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control; D008875:Middle Aged; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy*; D011446:Prospective Studies; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents