ART offer at antenatal clinics doubles uptake in Lusaka

Integration of antiretroviral treatment into public sector antenatal care (ANC) clinics in Lusaka district, Zambia, more than doubled the percentage of treatment-eligible pregnant women starting antiretroviral treatment before delivery when compared to referral from ANC clinics to antiretroviral clinics, reported William P. Killam and colleagues in a study published in the advance online edition of AIDS.

Forty-four percent of women eligible for antiretroviral treatment enrolled within 60 days of HIV diagnosis in the integrated programme compared to 25% who enrolled in separate ART clinics (the control group).

Thirty-three percent of women in the integrated programme began antiretroviral treatment compared to 14% in the control group.

The World Health Organization (WHO) reports an estimated 45% of pregnant HIV-positive women in low- and middle-income countries are receiving antiretroviral treatment, a third of whom get single-dose nevirapine, the least effective form of preventive treatment. Twenty-one percent of pregnant women received an HIV test in 2008. Only a third of those who tested positive were assessed to determine if they needed ART for their own health.

WHO recommends the provision of triple drug combination regimens to treatment-eligible HIV-infected women to protect both their infants from HIV infection and reduce maternal morbidity and mortality. Antiretroviral therapy is recommended for all with CD4 counts below 200 irrespective of symptoms and for people with WHO stage 3 HIV disease if the CD4 count is below 350.

In Zambia as in other parts of the region the presence of public sector antiretroviral clinics does not guarantee that all treatment-eligible pregnant women will actually use them after referral. Prior to this study, less than three percent of HIV-infected women in Lusaka, Zambia using public sector facilities began ART during pregnancy. The model of care was referral from the antenatal care clinic to a separate ART clinic located on the same site, but physically separate and staffed separately.

In October 2007 the authors introduced a programme providing antiretroviral treatment within the eight busiest Lusaka district public health sector antenatal care (ANC) clinics, called ART in ANC to try and increase use of antiretroviral treatment among HIV-positive pregnant women.

Between October 2007 and May 2008 the programme was rolled out one clinic at a time (stepped-wedge design).

The eight sites were matched into four pairs based on the number of HIV-positive pregnant women expected at each site. All participating clinics began collecting data at the same time while providing the standard of care (referral to ART clinic). Then one by one each clinic crossed over to the ART in ANC intervention. This design allowed for each clinic to provide patients to both arms of the comparison. Each clinic acted as its own control.

Both the separate ART and ART in ANC clinics used the same schedules, laboratory evaluations, record and quality assurance systems. The same cadres of personnel with identical ART training staffed both.

Of the 37,203 patients who began antenatal care in the eight clinics between 16 July 2007 and 31 July 2008, 15% (5667) began antenatal care 60 days before the intervention began. Given the potential for this group to be identified as treatment-eligible in the control period and then start ART in the intervention period they were excluded from the analysis to avoid any potential ambiguity.

37% (13,917) were identified as the referral to ART services (control) cohort (the existing standard of care), as antenatal care began more than 60 days before the start of the intervention. 47% (17,619) started antenatal care 60 days after the intervention began and were classified as the integrated ART in ANC (intervention) cohort.

The study was successful in its aim of finding ways to increase the provision of antiretroviral treatment to eligible pregnant women succeeded.

ART integration into antenatal care clinics more than doubled the percentage of HIV-positive pregnant women starting antiretroviral treatment. The average time women were on ART prior to delivery was at least ten weeks in both cohorts. Studies have shown that using ART for longer than seven weeks before delivery is more likely to result in suppression of viral load and provides a less than one percent risk of perinatal transmission.

The authors note the strengths of the study 1) a large cohort of women in antenatal care were assessed for ART eligibility in eight busy public sector PMTCT programme sites 2) an integrated electronic patient record system captured comprehensive patient information from ART eligibility, enrollment, starting ART and retention. 3) The phased rollout allows for a controlled evaluation unbiased by time trends and means that all sites are able to benefit from the improved strategy.

A potential weakness, the authors note, is the failure to directly report incidence of infant HIV infection or HIV-free survival. However, they argue that the primary challenge in prevention of mother-to-child transmission (PMTCT) is not whether ART is safe or effective in the prevention of infant HIV infection. Studies have already ably demonstrated this. The main issue, they argue, is increasing coverage of eligible women.

The 90-day retention rate in both cohorts was approximately 90%, and the authors made a programmatic decision to keep women in the integrated clinic until weaning at approximately six months after delivery.

The authors suggest possible reasons why this integrated approach is more effective than the previous standard of care model (referral from ANC to a separate ART clinic):

• Pregnant women may want to avoid enrolling in over crowded ART clinics and not deal with having to go to two separate clinics for care
• Poor staff attitudes in ART clinics toward pregnant women may be a factor; when ART is integrated into ANC staff are more likely to take ownership and initiative in counselling and follow-up of eligible patients
• An integrated clinic provides focus and interest in the provision of ART to eligible women.

While coverage more than doubled, over 60% of those in need are still not accessing treatment. The authors propose that further studies are needed to discover why, and “target strategies to improve uptake further”.

The authors conclude that “the cost and human resources involved in implementation of these strategies are areas for future analysis; however, in our setting, we have committed to deploying this strategy to other district clinics, believing it to be an essential step along the pathway to our ultimate goal of eradicating paediatric HIV and promoting maternal health.”