Targeted HIV research and care programmes may improve care for all pregnant women in Zambian clinics

A review of records from antenatal clinics in Lusaka, Zambia has found that pregnant women were screened for syphilis more commonly after prevention of mother-to-child HIV transmission (PMTCT) research and service programmes were implemented at the clinics. This increase in screening was interpreted as a marker of improved routine clinical services for pregnant women. The increase was only seen when research and service programmes had both been implemented; neither research nor service programs alone had a positive effect. The study was published in the January issue of the Journal of Acquired Immune Deficiency Syndromes.

Disease-specific research and/or care programmes, such as PMTCT, are often implemented in resource-limited settings, often with distinct funding sources and management. Little evidence to date has indicated how implementation of such programs may affect routine medical programme delivery – whether beneficially (e.g., by enhancing existing training and/or resources) or detrimentally (e.g., by reallocating existing and already strained resources).

In a preliminary investigation of this question, a research team reviewed records from 22 antenatal clinics in Lusaka, Zambia, at which PMTCT research and/or service programs had been implemented between 1997 and 2004.

Lusaka, the capital of Zambia, has an estimated population of 1.5 to 2.0 million, with the great majority of health care provided by a network of public clinics and one teaching hospital. Twenty-six of the clinics provide antenatal care; the 22 managed by Lusaka District were included in this study. Approximately 16% of the adult Zambian population is HIV-positive; HIV prevalence in urban antenatal clinics is as high as 30%.

As a "marker of good antenatal care," the research team investigated the prevalence of provision of rapid plasma reagin (RPR) syphilis screening, and follow-up penicillin treatment for women with positive RPR results. RPR provision was determined by systematic chart sampling and review; at each clinic, 50 records were sampled from time points before and after the point at which PMTCT research and/or care programs were implemented at each clinic. Prevalence odds ratios (PORs) were calculated to compare the rates of documented RPR and syphilis treatment coverage after PMTCT implementation at each clinic, as compared to before PMTCT implementation.

At the seven clinics which had PMTCT research (but not service) programmes, provision of RPR screening did not differ before and after the research programs were instituted: the prevalence odds ratio (POR) of RPR screening after PMTCT research introduction was 0.9 (95% confidence interval [CI], 0.7 to 1.1; p = 0.33) as compared to before. At the fifteen clinics with PMTCT service (but not research) programs, RPR screening was actually less frequent after service implementation, with a POR of 0.7 (95% CI, 0.5 to 0.8; p

This study is believed to be the first to assess the "benefit or harms of PMTCT research or service programs on ancillary antenatal care in a resource-limited setting." The findings suggest that neither PMTCT research nor service programmes on their own positively impacted "important and routine components of antenatal care", as indicated by provision of syphilis screening. However, a significant increase in such screening was seen when PMTCT research and service were implemented together.

The study was not designed to identify reasons for such effects, and so interpretation of these findings remains speculative. Improved RPR screening could have been a consequence of improvements in human, laboratory or supply resources; alternatively, the clinics selected for research and service program implementation may have had superior resources to begin with. Clinics with PMTCT services but no research programmes were found to have poorer RPR screening after PMTCT service implementation – a surprising finding that may indicate a diversion of existing resources to the PMTCT services.

Many clinic characteristics which could have affected capacity, including staff-to-patient ratios, staff training and experience, and measures of equipment procurement, were not assessed. The researchers believe that routine care provision "may depend in part on external funding for research or service programs to meet health system needs," and that these preliminary findings indicate that implementing such programmes "may be associated with … routine health care gains." However, the negative effect of implementing PMTCT services also shows that targeted programs may possibly harm existing services. Further research is recommended to assess the extent and nature of such effects and investigate the reasons for them.