title: Implementation and Operational Research: Effects of Antenatal Care and HIV Treatment Integration on Elements of the PMTCT Cascade: Results From the SHAIP Cluster-Randomized Controlled Trial in Kenya.
abstract: BACKGROUND
  Integrating antenatal care (ANC) and HIV care may improve uptake and retention in services along the prevention of mother-to-child transmission (PMTCT) cascade. This study aimed to determine whether integration of HIV services into ANC settings improves PMTCT service utilization outcomes.
  
  
  METHODS
  ANC clinics in rural Kenya were randomized to integrated (6 clinics, 569 women) or nonintegrated (6 clinics, 603 women) services. Intervention clinics provided all HIV services, including highly active antiretroviral therapy (HAART), whereas control clinics provided PMTCT services but referred women to HIV care clinics within the same facility. PMTCT utilization outcomes among HIV-infected women (maternal HIV care enrollment, HAART initiation, and 3-month infant HIV testing uptake) were compared using generalized estimating equations and Cox regression.
  
  
  RESULTS
  HIV care enrollment was higher in intervention compared with control clinics [69% versus 36%; odds ratio = 3.94, 95% confidence interval (CI): 1.14 to 13.63]. Median time to enrollment was significantly shorter among intervention arm women (0 versus 8 days, hazard ratio = 2.20, 95% CI: 1.62 to 3.01). Eligible women in the intervention arm were more likely to initiate HAART (40% versus 17%; odds ratio = 3.22, 95% CI: 1.81 to 5.72). Infant testing was more common in the intervention arm (25% versus 18%), however, not statistically different. No significant differences were detected in postnatal service uptake or maternal retention.
  
  
  CONCLUSIONS
  Service integration increased maternal HIV care enrollment and HAART uptake. However, PMTCT utilization outcomes were still suboptimal, and postnatal service utilization remained poor in both study arms. Further improvements in the PMTCT cascade will require additional research and interventions.
authors.affiliation: *Department of Health Care Organization and Policy, University of Alabama at Birmingham (UAB), Birmingham, AL; †Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Centre for Microbiology Research, Nairobi, Kenya; ‡Departments of Obstetrics, Gynecology, and Reproductive Sciences; §Medicine, University of California San Francisco (UCSF), San Francisco, CA; ‖Department of Obstetrics and Gynecology, Albert Einstein College of Medicine, New York, NY; ¶Division of Global HIV/AIDS (DGHA), US Centers for Disease Control and Prevention (CDC), Center for Global Health (CGH), Atlanta, GA; and #Department of Preventive and Promotive Health, Ministry of Health, Nairobi, Kenya.
authors.forename: Janet M
authors.initials: JM
authors.lastname: Turan
authors.forename: Maricianah
authors.initials: M
authors.lastname: Onono
authors.forename: Rachel L
authors.initials: RL
authors.lastname: Steinfeld
authors.forename: Starley B
authors.initials: SB
authors.lastname: Shade
authors.forename: Kevin
authors.initials: K
authors.lastname: Owuor
authors.forename: Sierra
authors.initials: S
authors.lastname: Washington
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Bukusi
authors.forename: Marta L
authors.initials: ML
authors.lastname: Ackers
authors.forename: Jackson
authors.initials: J
authors.lastname: Kioko
authors.forename: Evelyn C
authors.initials: EC
authors.lastname: Interis
authors.forename: Craig R
authors.initials: CR
authors.lastname: Cohen
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D016000:Cluster Analysis; D003151:Community Health Centers / Q000458:organization & administration*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000453:epidemiology / Q000517:prevention & control / Q000635:transmission*; D006284:Health Plan Implementation / Q000458:organization & administration*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D007630:Kenya / Q000453:epidemiology; D008430:Maternal-Child Health Centers / Q000458:organization & administration; D016017:Odds Ratio; D011247:Pregnancy; D011295:Prenatal Care / Q000458:organization & administration*; D012307:Risk Factors; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents