title: Implementation and Operational Research: Distance From Household to Clinic and Its Association With the Uptake of Prevention of Mother-to-Child HIV Transmission Regimens in Rural Zambia.
abstract: BACKGROUND
  In rural settings, HIV-infected pregnant women often live significant distances from facilities that provide prevention of mother-to-child transmission (PMTCT) services.
  
  
  METHODS
  We offered universal maternal combination antiretroviral regimens in 4 pilot sites in rural Zambia. To evaluate the impact of services, we conducted a household survey in communities surrounding each facility. We collected information about HIV status and antenatal service utilization from women who delivered in the past 2 years. Using household Global Positioning System coordinates collected in the survey, we measured Euclidean (i.e., straight line) distance between individual households and clinics. Multivariable logistic regression and predicted probabilities were used to determine associations between distance and uptake of PMTCT regimens.
  
  
  RESULTS
  From March to December 2011, 390 HIV-infected mothers were surveyed across four communities. Of these, 254 (65%) had household geographical coordinates documented. One hundred sixty-eight women reported use of a PMTCT regimen during pregnancy including 102 who initiated a combination antiretroviral regimen. The probability of PMTCT regimen initiation was the highest within 1.9 km of the facility and gradually declined. Overall, 103 of 145 (71%) who lived within 1.9 km of the facility initiated PMTCT versus 65 of 109 (60%) who lived farther away. For every kilometer increase, the association with PMTCT regimen uptake (adjusted odds ratio: 0.90, 95% confidence interval: 0.82 to 0.99) and combination antiretroviral regimen uptake (adjusted odds ratio: 0.88, 95% confidence interval: 0.80 to 0.97) decreased.
  
  
  CONCLUSIONS
  In this rural African setting, uptake of PMTCT regimens was influenced by distance to health facility. Program models that further decentralize care into remote communities are urgently needed.
authors.affiliation: *Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL; †Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; ‡Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC; §Institute for Global Health, Vanderbilt University, Nashville, TN; ‖Society for Family Health, Lusaka, Zambia; ¶Zambian Ministry of Community Development and Mother-Child Health, Lusaka, Zambia; #Department of Public Health, University of Zambia School of Medicine, Lusaka, Zambia; **Division of Infectious Diseases, Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC; ††Department of Epidemiology, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC; and ‡‡Currently at Departments of Medicine and Pediatrics, Massachusetts General Hospital; Boston, MA.
authors.forename: Veronica
authors.initials: V
authors.lastname: Escamilla
authors.forename: Carla J
authors.initials: CJ
authors.lastname: Chibwesha
authors.forename: Matthew
authors.initials: M
authors.lastname: Gartland
authors.forename: Namwinga
authors.initials: N
authors.lastname: Chintu
authors.forename: Mwangelwa
authors.initials: M
authors.lastname: Mubiana-Mbewe
authors.forename: Kebby
authors.initials: K
authors.lastname: Musokotwane
authors.forename: Patrick
authors.initials: P
authors.lastname: Musonda
authors.forename: William C
authors.initials: WC
authors.lastname: Miller
authors.forename: Jeffrey S A
authors.initials: JS
authors.lastname: Stringer
authors.forename: Benjamin H
authors.initials: BH
authors.lastname: Chi
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000453:epidemiology / Q000517:prevention & control / Q000635:transmission*; D006801:Humans; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008430:Maternal-Child Health Centers / Q000458:organization & administration; D016017:Odds Ratio; D010865:Pilot Projects; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy*; D011295:Prenatal Care / Q000458:organization & administration; D012307:Risk Factors; D012424:Rural Population; D014186:Transportation; D055815:Young Adult; D015024:Zambia / Q000453:epidemiology
chemical_list: D019380:Anti-HIV Agents