title: Implementation and Operational Research: Integration of PMTCT and Antenatal Services Improves Combination Antiretroviral Therapy Uptake for HIV-Positive Pregnant Women in Southern Zambia: A Prototype for Option B+?
abstract: BACKGROUND
  Early initiation of combination antiretroviral therapy (cART) for HIV-positive pregnant women can decrease vertical transmission to less than 5%. Programmatic barriers to early cART include decentralized care, disease-stage assessment delays, and loss to follow-up.
  
  
  METHODS
  Our intervention had 3 components: integrated HIV and antenatal services in 1 location with 1 provider, laboratory courier to expedite CD4 counts, and community-based follow-up of women-infant pairs to improve prevention of mother-to-child transmission attendance. Preintervention HIV-positive pregnant women were referred to HIV clinics for disease-stage assessment and cART initiation for advanced disease (CD4 count <350 cells/μL or WHO stage >2).
  
  
  METHODS
  We used a quasi-experimental design with preintervention/postintervention evaluations at 6 government antenatal clinics (ANCs) in Southern Province, Zambia. Retrospective clinical data were collected from clinic registers during a 7-month baseline period. Postintervention data were collected from all antiretroviral therapy-naive, HIV-positive pregnant women and their infants presenting to ANC from December 2011 to June 2013.
  
  
  RESULTS
  Data from 510 baseline women-infant pairs were analyzed and 624 pregnant women were enrolled during the intervention period. The proportion of HIV-positive pregnant women receiving CD4 counts increased from 50.6% to 77.2% [relative risk (RR) = 1.81; 95% confidence interval (CI): 1.57 to 2.08; P < 0.01]. The proportion of cART-eligible pregnant women initiated on cART increased from 27.5% to 71.5% (RR = 2.25; 95% CI: 1.78 to 2.83; P < 0.01). The proportion of eligible HIV-exposed infants with documented 6-week HIV PCR test increased from 41.9% to 55.8% (RR = 1.33; 95% CI: 1.18 to 1.51; P < 0.01).
  
  
  CONCLUSIONS
  Integration of HIV care into ANC and community-based support improved uptake of CD4 counts, proportion of cART-eligible women initiated on cART, and infants tested.
authors.affiliation: *Center for Global Health and Development, Boston University School of Public Health, Boston, MA; †Department of Pediatrics, Boston Medical Center, Boston, MA; ‡Department of Global Health, Boston University School of Public Health, Boston, MA; §Department of Pediatrics, University of California Davis, Sacramento, CA; ‖Zambia Center for Applied Health Research and Development, Lusaka, Zambia; ¶Marie Stopes International, Lilongwe, Malawi; #Centers for Disease Control and Prevention, Lusaka, Zambia; **Ministry of Community Development, Mother and Child Health, Government of the Republic of Zambia, Lusaka, Zambia; and ††Perinatal HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa.
authors.forename: Julie M
authors.initials: JM
authors.lastname: Herlihy
authors.forename: Leoda
authors.initials: L
authors.lastname: Hamomba
authors.forename: Rachael
authors.initials: R
authors.lastname: Bonawitz
authors.forename: Caitlin E
authors.initials: CE
authors.lastname: Goggin
authors.forename: Kennedy
authors.initials: K
authors.lastname: Sambambi
authors.forename: Jonas
authors.initials: J
authors.lastname: Mwale
authors.forename: Victor
authors.initials: V
authors.lastname: Musonda
authors.forename: Kebby
authors.initials: K
authors.lastname: Musokatwane
authors.forename: Kathryn L
authors.initials: KL
authors.lastname: Hopkins
authors.forename: Katherine
authors.initials: K
authors.lastname: Semrau
authors.forename: Emily E
authors.initials: EE
authors.lastname: Hammond
authors.forename: Julie
authors.initials: J
authors.lastname: Duncan
authors.forename: Anna B
authors.initials: AB
authors.lastname: Knapp
authors.forename: Donald M
authors.initials: DM
authors.lastname: Thea
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D065187:Controlled Before-After Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000635:transmission*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008297:Male; D055118:Medication Adherence; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy*; D011295:Prenatal Care / Q000379:methods / Q000458:organization & administration*; D012189:Retrospective Studies; D055815:Young Adult; D015024:Zambia
chemical_list: D044966:Anti-Retroviral Agents