Implementation and Operational Research: Effects of Antenatal Care and HIV Treatment Integration on Elements of the PMTCT Cascade: Results From the SHAIP Cluster-Randomized Controlled Trial in Kenya

Abstract

Background: Integrating antenatal care (ANC) and HIV care may improve uptake and retention in services along the prevention of mother-to-child transmission (PMTCT) cascade. This study aimed to determine whether integration of HIV services into ANC settings improves PMTCT service utilization outcomes.

Methods: ANC clinics in rural Kenya were randomized to integrated (6 clinics, 569 women) or nonintegrated (6 clinics, 603 women) services. Intervention clinics provided all HIV services, including highly active antiretroviral therapy (HAART), whereas control clinics provided PMTCT services but referred women to HIV care clinics within the same facility. PMTCT utilization outcomes among HIV-infected women (maternal HIV care enrollment, HAART initiation, and 3-month infant HIV testing uptake) were compared using generalized estimating equations and Cox regression.

Results: HIV care enrollment was higher in intervention compared with control clinics [69% versus 36%; odds ratio = 3.94, 95% confidence interval (CI): 1.14 to 13.63]. Median time to enrollment was significantly shorter among intervention arm women (0 versus 8 days, hazard ratio = 2.20, 95% CI: 1.62 to 3.01). Eligible women in the intervention arm were more likely to initiate HAART (40% versus 17%; odds ratio = 3.22, 95% CI: 1.81 to 5.72). Infant testing was more common in the intervention arm (25% versus 18%), however, not statistically different. No significant differences were detected in postnatal service uptake or maternal retention.

Conclusions: Service integration increased maternal HIV care enrollment and HAART uptake. However, PMTCT utilization outcomes were still suboptimal, and postnatal service utilization remained poor in both study arms. Further improvements in the PMTCT cascade will require additional research and interventions.

Figure 1. Map showing distribution of study sites in Southern Nyanza

Figure 2. Consort Diagram. The flow diagram of clusters and individuals through the cluster randomized trial

^a The number of pregnant women known to be HIV-positive before the ANC visit may have been underestimated if some women who knew themselves to be HIV-positive did not disclose their status to the health worker and chose to undergo additional HIV testing for confirmation. ^b The total number of HIV-positive women (known HIV-positives before the ANC visit plus those who tested HIV-positive during an ANC visit) may be underestimated, as these data were abstracted from routine ANC registers, which may not be complete. The need to rely on these different data sources resulted in lack of agreement for some totals presented in this figure. ^c The number of women who declined to participate may be over-estimated, as some women who declined to participate in the study during their first ANC visit may have accepted study enrollment during a subsequent ANC visit.

Figure 3. Elements of the PMTCT cascade completed for HIV-positive pregnant women attending intervention and control sites (proportions are based on all women enrolled in the study in each study arm)

* Only applicable for women who enrolled in HIV care ** Only applicable for women who were eligible for HAART