Integrating interventions for prevention of transmission of HIV from mothers to infants during pregnancy, delivery and breastfeeding with other healthcare services to increase the coverage

Ninety per cent of HIV infections in children under the age of 15 are a consequence of mother-to-child transmission of HIV during pregnancy, delivery and breastfeeding. In high-income countries introduction of prevention of mother-to-child HIV transmission (PMTCT) programmes reduced the rate of transmission of HIV from mothers to infants to 1%. These programmes consist of HIV testing, antiretroviral prophylaxis or therapy, safe obstetric practices and infant feeding counselling. PMTCT programmes have been implemented in low- and middle-income countries with variable success. One of the World Health Organization’s proposed strategies to increase the coverage and quality of PMTCT programmes is to provide them within other healthcare services used by pregnant women, mothers and children: e.g. maternal and child health care services. We assessed the effectiveness of integrated PMTCT programmes compared to non-integrated and partially integrated care. We defined effectiveness as increased PMTCT programme uptake. We searched a number of databases for relevant studies. From the initial list of 28,654 references, only one study met the inclusion criteria. This study was conducted in 12 antenatal clinics in Zambia. Six intervention clinics implemented HIV testing of women of unknown serostatus and assessment of antiretroviral prophylaxis adherence of HIV positive women. In six control clinics, HIV testing was not performed at labour ward and HIV positive women were informally asked if they took antiretroviral prophylaxis. In all 12 clinics, women were provided with antiretroviral prophylaxis at labour ward if found to be HIV positive and non-adherent to antiretroviral prophylaxis. All children born to HIV positive women were also given antiretroviral prophylaxis. A significant increase in proportion of women and children receiving antiretroviral prophylaxis was observed in the clinics that implemented the PMTCT interventions (of HIV testing and assessment of adherence to antiretroviral prophylaxis) compared to the control clinics. Women and children were more likely to receive antiretroviral prophylaxis at labour wards in the intervention clinics compared to control clinics. Although this one study showed that integrated care improved nevirapine coverage of women and infants more than non-integrated care, the paucity of evidence to confirm or refute this finding more widely suggests more research is urgently needed in other settings to allow a definitive conclusion about the effectiveness of integration of PMTCT interventions with other health services.

Authors' conclusions: 

We found only one study suggesting that integrating perinatal PMTCT interventions with other healthcare services in low- and middle-income countries increases the proportion of pregnant women, mothers and infants receiving PMTCT intervention. The weak evidence base does not enable making any inferences for other countries or contexts. The study that met the inclusion criteria assessed only the impact of integrating PMTCT intervention in labour ward on the proportion of mothers and their infants receiving nevirapine. The study showed significant improvement in intervention coverage but it only addressed the labour ward aspect of PMTCT programme. We did not find sufficient evidence to make definitive conclusions about the effectiveness of integration of these interventions with other health services rather than providing them as stand-alone services. Further research is urgently needed to assess the effect of integrating perinatal prevention of mother-to-child HIV transmission interventions with other health services on intervention coverage, service uptake, quality of care and health outcomes and the optimal integration modality.

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Background: 

Every year nearly 400,000 children are infected with HIV through mother-to-child transmission (MTCT), which is responsible for more than 90% of HIV infections in children. In high-income countries, the MTCT rate is less than 1% through perinatal prevention of mother-to-child HIV transmission (PMTCT) interventions. In low- and middle-income countries, PMTCT programme coverage remains low and consequently transmission rate high. The World Health Organisation recommends integration of PMTCT programmes with other healthcare services to increase access and improve uptake of these interventions.

Objectives: 

To assess the effect of integration of perinatal PMTCT measures with other health care services on coverage and service uptake compared to stand-alone PMTCT programmes and healthcare services or partially integrated PMTCT interventions.

Search strategy: 

We searched the following databases, for the time period of January 1990 to August 2010: MEDLINE, EMBASE, the WHO Global Health Library, CAB abstracts, CINAHL, POPLINE, PsycINFO, Sociological Abstracts, ERIC, AEGIS, Google Scholar, New York Academy of Medicine Grey Literature, Open SIGLE, British Library Catalogue, ProQuest Dissertation & Theses Database and U.S. National Library of Medicine Gateway system. We also searched the Cochrane Database of Systematic Reviews (the Cochrane Library 2010, Issue 7), the Cochrane Central Register of Controlled Trials (the Cochrane Library 2010, Issue 7), Database of Abstracts of Reviews on Effects (the Cochrane Library 2010, Issue 7). We also searched for ongoing trials in the WHO International Clinical Trials Registry and Controlled clinical trials (January 1990 to July 2010). We performed ISI Web of Knowledge Cited Reference Search and scanned the reference lists of the included articles for additional relevant studies. We contacted authors to locate additional eligible studies. To maximise sensitivity we did not employ any methodological filters.

Selection criteria: 

Randomised controlled trials (RCT), cluster-randomised controlled trials (cluster RCT), controlled clinical trials (CCT), controlled before and after (CBA) studies and interrupted time series (ITS) studies comparing integrated PMTCT interventions to non-integrated or partially integrated care for pregnant women, mothers and their infants in low- and middle-income countries.

Data collection and analysis: 

Two review authors independently ran the searches, selected studies, assessed methodological quality, and extracted data. The third review author resolved any disagreements.

Main results: 

Only one study met the inclusion criteria. A cluster-randomised trial (12 clusters, n=7664), compared mother-infant nevirapine coverage at labour ward between intervention clinics implementing rapid HIV testing with structured nevirapine assessment and control clinics implementing informal assessment of nevirapine adherence. The authors measured nevirapine coverage in all clinics at baseline and after the implementation of the intervention. An increase of 10% (range of difference in coverage from -10% to +33%) was observed in the intervention sites compared to 10% decline in mother-infant coverage in the control sites (range of difference in coverage from -13% to 0%). The study showed that the probability of nevirapine coverage of mothers and their infants in the intervention arm compared to control arm increased from 0.89 at baseline to 1.22 during the intervention period, representing a multiplicative effect of 1.37 upon the ratio of relative risks at baseline (RR 1.37, bootstrapped 95% CI, 1.041.77). The study had a low risk of bias. No studies were found that evaluated the effectiveness of integrating other perinatal PMTCT interventions with healthcare services.

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