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

Edmonds, Andrew; Feinstein, Lydia; Okitolonda, Vitus; Thompson, Deidre; Kawende, Bienvenu; Behets, Frieda

doi:10.1097/QAI.0000000000000781

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

Published Date:

Dec 01 2015

Publisher's site:

http://dx.doi.org/10.1097/QAI.0000000000000781 New Site Icon

Source:

J Acquir Immune Defic Syndr. 70(4):e130-e139

Language:

English

[PDF-275.04 KB]

Details:

Personal Authors:

Edmonds, Andrew ; Feinstein, Lydia ; Okitolonda, Vitus ; Thompson, Deidre ; Kawende, Bienvenu ; ... More ▼

Keywords:

[+]

Pubmed ID:

26262776

Pubmed Central ID:

PMC4856046

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.

Document Type:

Journal Article

Collection(s):

CDC Public Access

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

Place as Subject:

Democratic Republic of the Congo

Main Document Checksum:

[+]

Supporting Files:

	NIHMS759581-supplement-SDC.pdf	application/pdf
	nihms759581.nxml	text/xml
	nihms759581f1.gif	image/gif
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	nihms759581f3.jpg	image/jpeg

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