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:
  Adolescent Adult Anti-Retroviral Agents Cohort Studies Delivery Of Health Care Democratic Republic Of Congo Democratic Republic Of The Congo Female Health Services Accessibility HIV Infections Humans Infant Infant, Newborn Infectious Disease Transmission, Vertical Medication Adherence Postnatal Care Postnatal Care/Utilization Pregnancy Pregnancy Complications, Infectious Prenatal Care Prenatal Care/Utilization Prevention Of Mother To Child Transmission Vertical Transmission Young Adult

  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
• Collection(s):
  CDC Public Access
• Main Document Checksum:
  urn:sha256:ac5a38d8f3f092f2ceb6a289e0839265e2a8b45e533484ade6134b18f4a7724e
• Download URL:
  https://stacks.cdc.gov/view/cdc/42112/cdc_42112_DS1.pdf
• File Type:
  [PDF - 275.04 KB ]