Using the PMTCT Cascade to Accelerate Achievement of the Global Plan Goals

Abstract

Background: Development of country plans for prevention of mother-to-child HIV transmission (PMTCT), including expansion of comprehensive, integrated services, was key to Global Plan achievements.

Approaches: Use of the PMTCT cascade, an evolving series of sequential steps needed to maximize the health of women and HIV-free survival of infants, was critical for development and implementation of PMTCT plans. Regular review of cascade data at national/subnational levels was a tool for evidence-based decision making, identifying areas of greatest need at each level, and targeting program interventions to address specific gaps. Resulting improvements in PMTCT service delivery contributed to success. Populating the cascade highlighted limitations in data availability and quality that focused attention on improving national health information systems.

Limitations: Use of aggregate, cross-sectional data in the PMTCT cascade presents challenges in settings with high mobility and weak systems to track women and children across services. Poor postnatal follow-up and losses at each step of the cascade have limited use of the cascade approach to measure maternal and child health outcomes beyond the early postnatal period.

Lessons learned: A cascade approach was an effective means for countries to measure progress, identify suboptimal performance areas, and be held accountable for progress toward achievement of Global Plan goals. Using the cascade requires investment of time and effort to identify the type, source, and quality of data needed as programs evolve. Ongoing review of cascade data, with interventions to address discontinuities in the continuum of care, can translate across health areas to improve health care quality and outcomes.

FIGURE 1.

As WHO guidelines have evolved over time, key indicators included in the PMTCT cascade have changed, as shown by X, with bolded X representing the introduction of new indicators.^– ART, antiretroviral therapy; ARV, antiretroviral.

FIGURE 2.

An expanded PMTCT cascade is required to measure progress toward Global Plan goals for elimination of HIV infection in children and keeping mothers alive as in this illustrative example. Parallel but linked maternal and child cascades that begin with all pregnant women and include data on HIV infection, mortality, and HIV treatment endpoints at 18–24 months would enable more comprehensive understanding of the progress and gaps in achieving PMTCT and MCH goals. ART, antiretroviral therapy; ARV, antiretroviral; L&D, labor and delivery; PNC, postnatal care.

FIGURE 3.

Barker's et al cascade analysis illustrates that HIV transmission rates are driven by mother–infant pairs who fall out of the cascade and do not receive the necessary services. This demonstrates the importance of improving PMTCT service delivery, not only implementing the PMTCT regimen change to antiretroviral (ARV) therapy for all women, in reaching Global Plan goals for elimination of new infections in children. Reprinted with permission from J Acquir Immune Defic Syndr. 2011;56:e45–e48. Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of the copyright in the translation or adaptation.

FIGURE 4.

Gap analysis using the cascade can identify missed opportunities for prevention and treatment, and the steps that programs can take to address them. Data from the Elizabeth Glaser Pediatric AIDS Foundation-supported programs in the United Republic of Tanzania in 2010 and 2015 are shown as an example of gap analyses. Some actions taken in response to gaps identified in 2010 are listed with resultant improvements demonstrated in 2015. ART, antiretroviral therapy; ARV, antiretroviral; CTX, cotrimoxazole.

FIGURE 5.

PMTCT cascade results from South African surveillance activities in 2010–2013 reflect an increase in access to antiretroviral therapy for pregnant women after implementation of the 2010 WHO guidelines and gaps in the PMTCT cascade for EID and retesting of HIV-negative women (only measured beginning in 2012). ART, antiretroviral therapy; ARV, antiretroviral; PCR, polymerase chain reaction. Reprinted with permission from: Goga et al. Available at: http://www.mrc.ac.za/healthsystems/SAPMTCTEReport2012.pdf. Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.