Decentralization Does Not Assure Optimal Delivery of PMTCT and HIV-Exposed Infant Services in a Low Prevalence Setting

Details

• Alternative Title:
  J Acquir Immune Defic Syndr
• Personal Author:
  Edmonds, Andrew ; Feinstein, Lydia ; Okitolonda, Vitus ; Thompson, Deidre ; Kawende, Bienvenu ; Behets, Frieda
• Description:
  Background ; 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. ; Methods ; 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. ; Results ; 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. ; Conclusions ; 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.
• Keywords:
  • prevention of mother to child transmission
  • vertical transmission
  • Democratic Republic of Congo
  • health services accessibility
  • delivery of health care
  • prenatal care/utilization
  • postnatal care/utilization
  • Adolescent
  • Adult
  • Anti-Retroviral Agents
  More +
• Source:
  J Acquir Immune Defic Syndr. 70(4):e130-e139
• Pubmed ID:
  26262776
• Pubmed Central ID:
  PMC4856046
• Document Type:
  Journal Article
• Funding:
  U2G PS001179/PS/NCHHSTP CDC HHSUnited States/ ; P30-AI50410/AI/NIAID NIH HHSUnited States/ ; T32 HD007168/HD/NICHD NIH HHSUnited States/ ; T32 AI070114/AI/NIAID NIH HHSUnited States/ ; P2C HD050924/HD/NICHD NIH HHSUnited States/ ; P30 AI050410/AI/NIAID NIH HHSUnited States/
• Volume:
  70
• Issue:
  4
• Download URL:
  https://stacks.cdc.gov/view/cdc/42112/cdc_42112_DS1.pdf
• File Type:
  [PDF - 275.04 KB]
• Collection(s):
  CDC Public Access
• Main Document Checksum:
  urn:sha256:ac5a38d8f3f092f2ceb6a289e0839265e2a8b45e533484ade6134b18f4a7724e