title: Evaluation of a Systems Analysis and Improvement Approach to Optimize Prevention of Mother-To-Child Transmission of HIV Using the Consolidated Framework for Implementation Research.
abstract: Despite large investments to prevent mother-to-child-transmission (PMTCT), pediatric HIV elimination goals are not on track in many countries. The Systems Analysis and Improvement Approach (SAIA) study was a cluster randomized trial to test whether a package of systems engineering tools could strengthen PMTCT programs. We sought to (1) define core and adaptable components of the SAIA intervention, and (2) explain the heterogeneity in SAIA's success between facilities.
  
  
  
  The Consolidated Framework for Implementation Research (CFIR) guided all data collection efforts. CFIR constructs were assessed in focus group discussions and interviews with study and facility staff in 6 health facilities (1 high-performing and 1 low-performing site per country, identified by study staff) in December 2014 at the end of the intervention period. SAIA staff identified the intervention's core and adaptable components at an end-of-study meeting in August 2015. Two independent analysts used CFIR constructs to code transcripts before reaching consensus.
  
  
  
  Flow mapping and continuous quality improvement were the core to the SAIA in all settings, whereas the PMTCT cascade analysis tool was the core in high HIV prevalence settings. Five CFIR constructs distinguished strongly between high and low performers: 2 in inner setting (networks and communication, available resources) and 3 in process (external change agents, executing, reflecting and evaluating).
  
  
  
  The CFIR is a valuable tool to categorize elements of an intervention as core versus adaptable, and to understand heterogeneity in study implementation. Future intervention studies should apply evidence-based implementation science frameworks, like the CFIR, to provide salient data to expand implementation to other settings.
authors.affiliation: *Department of Family and Child Nursing, University of Washington, Seattle, WA; †Department of Global Health, University of Washington, Seattle, WA; ‡Health Alliance International, Seattle, WA; §Health Alliance International, Bouake, Cote d'Ivoire; ‖Health Alliance International, Beira, Mozambique; ¶Department of Pediatrics, University of Nairobi, Nairobi, Kenya; #Network of AIDS Researchers of Eastern and Southern Africa (NARESA), Nairobi, Kenya; **Beira Operations Research Center(CIOB), Beira, Mozambique; and ††Sofala Provincial Department of Health, Beira, Mozambique.
authors.forename: Sarah
authors.initials: S
authors.lastname: Gimbel
authors.forename: Alison S
authors.initials: AS
authors.lastname: Rustagi
authors.forename: Julia
authors.initials: J
authors.lastname: Robinson
authors.forename: Seydou
authors.initials: S
authors.lastname: Kouyate
authors.forename: Joana
authors.initials: J
authors.lastname: Coutinho
authors.forename: Ruth
authors.initials: R
authors.lastname: Nduati
authors.forename: James
authors.initials: J
authors.lastname: Pfeiffer
authors.forename: Stephen
authors.initials: S
authors.lastname: Gloyd
authors.forename: Kenneth
authors.initials: K
authors.lastname: Sherr
authors.forename: S Adam
authors.initials: SA
authors.lastname: Granato
authors.forename: Ahoua
authors.initials: A
authors.lastname: Kone
authors.forename: Emilia
authors.initials: E
authors.lastname: Cruz
authors.forename: Joao Luis
authors.initials: JL
authors.lastname: Manuel
authors.forename: Justina
authors.initials: J
authors.lastname: Zucule
authors.forename: Manuel
authors.initials: M
authors.lastname: Napua
authors.forename: Grace
authors.initials: G
authors.lastname: Mbatia
authors.forename: Grace
authors.initials: G
authors.lastname: Wariua
authors.forename: Martin
authors.initials: M
authors.lastname: Maina
mesh_terms: D007560:Cote d'Ivoire; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000635:transmission*; D006801:Humans; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy*; D013597:Systems Analysis