title: Implementation and Operational Research: An Integrated and Comprehensive Service Delivery Model to Improve Pediatric and Maternal HIV Care in Rural Africa.
abstract: BACKGROUND
  Strategies to improve HIV diagnosis and linkage into care, antiretroviral treatment coverage, and treatment outcomes of mothers and children are urgently needed in sub-Saharan Africa.
  
  
  METHODS
  From December 2012, we implemented an intervention package to improve prevention of mother-to-child transmission (PMTCT) and pediatric HIV care in our rural Tanzanian clinic, consisting of: (1) creation of a PMTCT and pediatric unit integrated within the reproductive and child health clinic; (2) implementation of electronic medical records; (3) provider-initiated HIV testing and counseling in the hospital wards; and (4) early infant diagnosis test performed locally. To assess the impact of this strategy, clinical characteristics and outcomes were compared between the period before (2008-2012) and during/after the implementation (2013-2014).
  
  
  RESULTS
  After the intervention, the number of mothers and children enrolled into care almost doubled. Compared with the pre-intervention period (2008-2012), in 2013-2014, children presented lower CD4% (16 vs. 16.8, P = 0.08) and more advanced disease (World Health Organization stage 3/4 72% vs. 35%, P < 0.001). The antiretroviral treatment coverage rose from 80% to 98% (P < 0.001), the lost-to-follow-up rate decreased from 20% to 11% (P = 0.002), and mortality ascertainment improved. During 2013-2014, 261 HIV-exposed infants were enrolled, and the early mother-to-child transmission rate among mother-infant pairs accessing PMTCT was 2%.
  
  
  CONCLUSIONS
  This strategy resulted in an increased number of mothers and children diagnosed and linked into care, a higher detection of children with AIDS, universal treatment coverage, lower loss to follow-up, and an early mother-to-child transmission rate below the threshold of elimination. This study documents a feasible and scalable model for family-centered HIV care in sub-Saharan Africa.
authors.affiliation: *Swiss Tropical and Public Health Institute, Basel, Switzerland; †University of Basel, Basel, Switzerland; ‡Ifakara Health Institute, Ifakara, United Republic of Tanzania; §Ministry of Health and Social Welfare, Dar es Salaam, United Republic of Tanzania; ‖Saint Francis Referral Hospital, Ifakara, United Republic of Tanzania; ¶Saint Francis University College of Health and Allied Sciences, Ifakara, United Republic of Tanzania; #Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland; and **ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
authors.forename: Anna
authors.initials: A
authors.lastname: Gamell
authors.forename: Tracy R
authors.initials: TR
authors.lastname: Glass
authors.forename: Lameck B
authors.initials: LB
authors.lastname: Luwanda
authors.forename: Herry
authors.initials: H
authors.lastname: Mapesi
authors.forename: Leila
authors.initials: L
authors.lastname: Samson
authors.forename: Tom
authors.initials: T
authors.lastname: Mtoi
authors.forename: Angelo
authors.initials: A
authors.lastname: Nyamtema
authors.forename: Lukas
authors.initials: L
authors.lastname: Muri
authors.forename: Alex
authors.initials: A
authors.lastname: Ntamatungiro
authors.forename: Marcel
authors.initials: M
authors.lastname: Tanner
authors.forename: Christoph
authors.initials: C
authors.lastname: Hatz
authors.forename: Manuel
authors.initials: M
authors.lastname: Battegay
authors.forename: Emilio
authors.initials: E
authors.lastname: Letang
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy / Q000517:prevention & control*; D006801:Humans; D007223:Infant; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008297:Male; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy*; D015397:Program Evaluation; D011446:Prospective Studies; D012424:Rural Population; D013636:Tanzania
chemical_list: D019380:Anti-HIV Agents