Decentralization Does Not Assure Optimal Delivery of PMTCT and HIV-Exposed Infant Services in a Low Prevalence Setting
Published Date:Dec 1 2015
Source:J Acquir Immune Defic Syndr. 70(4):e130-e139.
Delivery Of Health Care
Democratic Republic Of Congo
Democratic Republic Of The Congo
Health Services Accessibility
Infectious Disease Transmission, Vertical
Pregnancy Complications, Infectious
Prevention Of Mother To Child Transmission
Pubmed Central ID:PMC4856046
Funding:U2G PS001179/PS/NCHHSTP CDC HHS/United States
U62/CCU422422/PHS HHS/United States
P30-AI50410/AI/NIAID NIH HHS/United States
5U2GPS001179-01/PHS HHS/United States
T32 HD007168/HD/NICHD NIH HHS/United States
T32 AI070114/AI/NIAID NIH HHS/United States
P2C HD050924/HD/NICHD NIH HHS/United States
P30 AI050410/AI/NIAID NIH HHS/United States
The consequences of decentralizing prevention of mother-to-child HIV transmission and HIV-exposed infant services to antenatal care (ANC)/labor and delivery (L&D) sites from dedicated HIV care and treatment (C&T) centers remain unknown, particularly in low prevalence settings.
In a cohort of mother–infant pairs, we compared delivery of routine services at ANC/L&D and C&T facilities in Kinshasa, Democratic Republic of Congo from 2010–2013, using methods accounting for competing risks (eg, death). Women could opt to receive interventions at 90 decentralized ANC/L&D sites, or 2 affiliated C&T centers. Additionally, we assessed decentralization’s population-level impacts by comparing proportions of women and infants receiving interventions before (2009–2010) and after (2011–2013) decentralization.
Among newly HIV-diagnosed women (N = 1482), the 14-week cumulative incidence of receiving the package of CD4 testing and zidovudine or antiretroviral therapy was less at ANC/L&D [66%; 95% confidence interval (CI): 63% to 69%] than at C&T (88%; 95% CI: 83% to 92%) sites (subdistribution hazard ratio, 0.62; 95% CI: 0.55 to 0.69). Delivery of cotrimoxazole and DNA polymerase chain reaction testing to HIV-exposed infants (N = 1182) was inferior at ANC/L&D sites (subdistribution hazard ratio, 0.84; 95% CI: 0.76 to 0.92); the 10-month cumulative incidence of the package at ANC/L&D sites was 89% (95% CI: 82% to 93%) versus 97% (95% CI: 93% to 99%) at C&T centers. Receipt of the pregnancy (20% of 1518, to 64% of 1405) and infant (16%–31%) packages improved post decentralization.
Services were delivered less efficiently at ANC/L&D sites than C&T centers. Although access improved with decentralization, its potential cannot be realized without sufficient and sustained support.
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