19 Sep 2016
Gloyd S; Granato SA; Billy DA; Robinson; Abo K; Kouyate S; Kourai V; Bla C; Djety G; Rowan HB; Squires E; Wagenaar B; Kone A (2016) National-level Analysis of the PMTCT Option B Program and Intervention to Improve Retention in Côte d’Ivoire. USAID
Since 2000, the World Health Organization (WHO) has recommended the use of antiretroviral drugs (ARVs) in the prevention of mother-to-child transmission of HIV (PMTCT). Nevertheless, national-level studies on PMTCT effectiveness and global estimates have highlighted maternal retention in care as a key implementation challenge, with global retention rates estimated at 34 percent in 2010. The most recent policy revision, adopted in 2012, recommended that countries consider contextual factors when operationalizing either the PMTCT Option B or Option B+ approach1 to ensure programmatic and operational effectiveness. In Côte d’Ivoire, PMTCT has been a national policy since 2004 with mixed success. In November 2012, the Ministère de la Santé et de l’Hygiène Publique (MSHP), Côte d’Ivoire Ministry of Health and Public Hygiene, formally adopted WHO’s Option B regimen with scale-up to national implementation occurring over the course of 2013. Given the challenges with earlier approaches to PMTCT, particularly with regard to patient retention, a robust national assessment of Option B was planned and carried out as the second phase in a two-phase national study on PMTCT through the United States Agency for International Development-funded, Population Council-led HIVCore project by a consortium including MSHP, the University of Washington (UW), and Health Alliance International (HAI). In addition to this retrospective Option B assessment, this project also included the implementation and assessment of an intervention designed to improve retention in care through information sharing and active patient tracking (APT).
The objectives of the study were to: (1) understand how the implementation of the Option B strategy impacted key measures of PMTCT effectiveness; (2) identify persistent and emerging bottlenecks in the system that affect service delivery and patient retention; and (3) measure the impact of implementing an inter-professional patient tracking intervention on patient retention in PMTCT services. This study was conducted under the United States International Agency for International Development-funded HIVCore project, led by the Population Council in partnership with Elizabeth Glaser Pediatric AIDS Foundation, Palladium, and the University of Washington.
This study was undertaken in a national sample of 50 randomly selected health care facilities that reported testing pregnant women for HIV in antenatal care (ANC) services in 2013 and reported 10 or more new HIV cases in the same year (n=368 eligible facilities). At each site, two study team members collected de-identified data from the following: (1) monthly reports and on-site registries for the time period August 2011–January 2016 (14 indicators over 54 months); (2) a sample of up to 60 patient charts of HIV-positive women enrolled in PMTCT services in 2012, 2014, and 2015 (up to 20 per year) (n=2,001); and (3) informal (n=92) and semi-structured (n=137) interviews with health care workers and community representatives. Our outcome measures of PMTCT effectiveness included HIV testing rate at first ANC visit, proportion of HIV-positive women presenting at ANC or maternity who received appropriate prophylaxis, and maternal retention in care at 6 and 12 months from ARV initiation and at six months from childbirth.
The APT intervention was implemented in a subset of 30 of the 50 study sites included in the Option B assessment. Intervention sites were purposively sampled based on accessibility, willingness to participate, and inclusion of a cross-section of health facility types (e.g., hospital, urban health center, NGO-run health facility). At each site, an intervention workshop was held to identify an inter-professional team of health care workers charged with meeting on a monthly basis to review PMTCT patient retention status. Each team was supplied with an active patient tracking toolkit consisting of four tools aimed at patient identification, chart identification, patient flow mapping, and health information system mapping. The intervention was rolled out in a stepwise manner, with six sites initiating the intervention monthly beginning in August 2015. Following initiation, study teams visited intervention sites monthly through March 2016 to collect de-identified data on patient chart availability, patient retention status, data on staffing levels, delegation of tasks, and training. The team also conducted semi-structured interviews with two APT team members each month.
Option B assessment data availability in monthly reports and registries improved under Option B. Over the 54-month study period (August 2011– January 2016), 20 percent of observations were missing from the 14 health information system (HIS) monthly reports and registry indicators collected from the study sites. However, the proportion of unrecorded data in reports dropped dramatically from 32 percent during the 12-month period preceding the national policy transition to Option B to 6 percent during the 12-month preceding the national policy transition to Option B+.
Chart availability remained low. We found that roughly half of HIV-positive women presenting in ANC in 2014 and 2015 at these same sites did not have a patient chart available at the facility at the time of data collection.
Rates of HIV testing and delivery of ARVs in ANC increased from Option A to Option B. Over the course of Option B implementation in Côte d’Ivoire, the testing rate increased nine percentage points, and the proportion of women initiating appropriate prophylaxis increased 14 percentage points.
Overall retention in care remained steady or decreased from Option A to Option B. Patient retention on lifelong ART at 6 and 12 months from initiation was similar between patients enrolled under Option A and those enrolled under Option B (six months: 77 percent vs. 73 percent; 12 months: 65 percent vs. 64 percent). Among patient charts belonging to patients enrolled under Option B, charts belonging to women on lifelong ART had higher recorded retention rates at six months from initiation and six months from childbirth than those belonging to patients prescribed ARVs as prophylaxis through antenatal care, delivery, and breastfeeding (73 percent vs. 66 percent; 60 percent vs. 47 percent, respectively).
The first 30 and 90 days of care were crucial to patient retention in PMTCT services under Option B. Among patient charts belonging to lifelong ART patients who were lost to follow-up at the time of data collection, 32 percent were lost within the first 30 days and half were lost within the first 90 days of enrollment. Among sites where staff frequently waited until after receiving CD4 results to enroll patients in care, loss to follow-up was 16 percent higher between HIV testing and delivery of ARVs to the patient than sites that did not wait.
Health systems and community-based factors contributed to patient loss to follow up. Despite an overall appreciation for the perceived impact of the Option B treatment regimen on mother and child health, both health systems and community-based factors continued to influence patient loss to follow-up under Option B. Health care workers frequently cited workforce, infrastructure, supply chain, and laboratory access as perceived factors that impact delivery of PMTCT services and patient retention in care. In the community, stigma and lack of financial means or access to transport were often cited as contributing to loss to follow-up, while facility-community linkages, patient outreach activities, and community education were seen as facilitators to retention.
Intervention assessment: Data triangulation between registry data and patient chart data helped to identify documentation gaps and improve data availability. Although patient retention rates calculated from patient charts collected prior to and following the APT intervention did not differ significantly, the total number of patient charts found on-site as a proportion of HIV-positive patients reported in ANC during the period increased significantly (57 percent to 76 percent, p=0.001), resulting in overall higher numbers of patients with documented retention in care. Informants overwhelmingly cited that the chart identification tool, which helped identify missing charts, was the most utilized tool during the intervention period.Regular, inter-professional meetings to review patient charts helped foster innovative, contextualized strategies to improve patient retention. Throughout the intervention period, sites reported efforts to reinforce existing patient retention strategies, and the identification of new strategies during monthly meetings. New strategies tended to focus on new tasks and task-shifting, information sharing, scheduling, and strengthening data systems.
CONCLUSION AND RECOMMENDATIONS
The study demonstrated substantial and consistent loss to follow-up at multiple steps in the PMTCT Option B cascade in Cote d’Ivoire. A combination of registry and patient chart data indicated that 21 percent of HIV-positive pregnant women with known status did not receive any ARVs; and among those who did, a third were lost to follow up within six months of initiation. After accounting for gaps in testing, initiation of ARVs, loss of patient charts, and documented retention in charts that were found, less than a third of HIV-positive pregnant women attending antenatal care showed documented evidence of being actively retained in appropriate HIV care at six months after initiation of care, and fewer at 12 months. Nevertheless, it is suspected that large numbers of additional women were retained in care without documented evidence in a patient chart. Although health care workers reported that they welcomed the Option B intervention as simpler and more acceptable to patients compared to previous PMTCT regimens, they described many factors that influenced the success of Option B, including staff training, roles, and motivation; working conditions such as space, stock outs, and availability of laboratories and medicines; stigma and lack of partner involvement; financial barriers, especially for transport; and differences in support by international NGO partners. The APT intervention was associated with significant improvement in the availability (and likely use) of patient charts to follow up patients; however, for the patient charts that were found there was not a significant difference in the proportion of women retained in care at 6 and 12 months following ARV initiation. Thus, the overall known number of women retained in care increased, as similar retention among a larger group of patients resulted in more available active (and inactive) charts. Health care providers reported that the monthly meetings allowed staff to come up with ideas (a mix of pre-existing and new strategies) to improve retention. Pre-existing strategies included individual patient follow-up with phone calls and home visits, reinforced counseling, provision of food and household supplies, informal follow-up notebooks, and community outreach. New strategies included task-shifting, improved information sharing, improvement in patient and information flow systems, and more consistent creation of patient charts. It is possible that a longer follow up period would have been necessary to determine whether the combination of new retention strategies and increased availability of charts would eventually lead to a higher retention rate among found charts.The results of this assessment and operations research study suggest that future efforts to curb patient loss to follow-up and ultimately prevent MTCT should focus on retaining mothers in care, with pointed emphasis on the first 30 and 90 days from enrollment. Efforts should focus on simplifying patient follow-up systems and information flow. Context-specific interventions that help to identify missing information or document service bottlenecks (such as stock-outs, workforce inadequacies, or service delays) are a critical first step to improving retention, and can and should be implemented at the health systems level. However, documentation of these efforts must be coupled with an active response from key government, NGO, and international funding agency stakeholders. Key actions should include simplification of data and reporting systems, human resource needs assessments, improved supply chain management, infrastructural rehabilitation, and new strategies for reducing stigma in the community.