title: Supply-side dimensions and dynamics of integrating HIV testing and counselling into routine antenatal care: a facility assessment from Morogoro Region, Tanzania.
abstract: BACKGROUND
  Integration of HIV into RMNCH (reproductive, maternal, newborn and child health) services is an important process addressing the disproportionate burden of HIV among mothers and children in sub-Saharan Africa. We assess the structural inputs and processes of care that support HIV testing and counselling in routine antenatal care to understand supply-side dynamics critical to scaling up further integration of HIV into RMNCH services prior to recent changes in HIV policy in Tanzania.
  
  
  METHODS
  This study, as a part of a maternal and newborn health program evaluation in Morogoro Region, Tanzania, drew from an assessment of health centers with 18 facility checklists, 65 quantitative and 57 qualitative provider interviews, and 203 antenatal care observations. Descriptive analyses were performed with quantitative data using Stata 12.0, and qualitative data were analyzed thematically with data managed by Atlas.ti.
  
  
  RESULTS
  Limitations in structural inputs, such as infrastructure, supplies, and staffing, constrain the potential for integration of HIV testing and counselling into routine antenatal care services. While assessment of infrastructure, including waiting areas, appeared adequate, long queues and small rooms made private and confidential HIV testing and counselling difficult for individual women. Unreliable stocks of HIV test kits, essential medicines, and infection prevention equipment also had implications for provider-patient relationships, with reported decreases in women's care seeking at health centers. In addition, low staffing levels were reported to increase workloads and lower motivation for health workers. Despite adequate knowledge of counselling messages, antenatal counselling sessions were brief with incomplete messages conveyed to pregnant women. In addition, coping mechanisms, such as scheduling of clinical activities on different days, limited service availability.
  
  
  CONCLUSIONS
  Antenatal care is a strategic entry point for the delivery of critical tests and counselling messages and the framing of patient-provider relations, which together underpin care seeking for the remaining continuum of care. Supply-side deficiencies in structural inputs and processes of delivering HIV testing and counselling during antenatal care indicate critical shortcomings in the quality of care provided. These must be addressed if integrating HIV testing and counselling into antenatal care is to result in improved maternal and newborn health outcomes.
authors.affiliation: Department of International Health, International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA. sjan@jhu.edu.
authors.forename: Selena J
authors.initials: SJ
authors.lastname: An
authors.affiliation: Department of International Health, International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA. ageorg22@jhu.edu.
authors.forename: Asha S
authors.initials: AS
authors.lastname: George
authors.affiliation: Department of International Health, International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA. aelefevre@gmail.com.
authors.forename: Amnesty E
authors.initials: AE
authors.lastname: LeFevre
authors.affiliation: Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, P.O. Box 65015, Dar es Salaam, Tanzania. rcmpembeni@gmail.com.
authors.forename: Rose
authors.initials: R
authors.lastname: Mpembeni
authors.affiliation: Department of Behavioural Sciences, Muhimbili University of Health and Allied Sciences, P.O. Box 65015, Dar es Salaam, Tanzania. ihmosha@yahoo.co.uk.
authors.forename: Idda
authors.initials: I
authors.lastname: Mosha
authors.affiliation: Department of International Health, International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA. dmohan3@jhmi.edu.
authors.forename: Diwakar
authors.initials: D
authors.lastname: Mohan
authors.affiliation: Department of International Health, International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA. annyang17@gmail.com.
authors.forename: Ann
authors.initials: A
authors.lastname: Yang
authors.affiliation: Department of International Health, International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA. jchebet1@jhu.edu.
authors.forename: Joy
authors.initials: J
authors.lastname: Chebet
authors.affiliation: Jhpiego, Dar es Salaam, Tanzania. chrisostom.lipingu@jhpiego.org.
authors.forename: Chrisostom
authors.initials: C
authors.lastname: Lipingu
authors.affiliation: Department of International Health, International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA. abaqui@jhu.edu.
authors.forename: Abdullah H
authors.initials: AH
authors.lastname: Baqui
authors.affiliation: Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, P.O. Box 65015, Dar es Salaam, Tanzania. jkillewo@yahoo.co.uk.
authors.forename: Japhet
authors.initials: J
authors.lastname: Killewo
authors.affiliation: Department of International Health, International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA. pwinch@jhu.edu.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Winch
authors.affiliation: Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, P.O. Box 65015, Dar es Salaam, Tanzania. kilewo1950@gmail.com.
authors.forename: Charles
authors.initials: C
authors.lastname: Kilewo
mesh_terms: D000293:Adolescent; D000328:Adult; D003376:Counseling; D019033:Delivery of Health Care, Integrated; D036861:Delivery, Obstetric; D005260:Female; D015658:HIV Infections / Q000517:prevention & control*; D006801:Humans; D007231:Infant, Newborn; D007407:Interviews as Topic; D008297:Male; D008403:Mass Screening; D008875:Middle Aged; D009035:Mothers; D011247:Pregnancy; D037841:Pregnant People; D011295:Prenatal Care; D015397:Program Evaluation; D036301:Qualitative Research; D012698:Serologic Tests; D013636:Tanzania; D055815:Young Adult