Antiretroviral therapy in antenatal care to increase treatment initiation in HIV-infected

Antiretroviral therapy in antenatal care to increase treatment initiation in HIV-infected pregnant women: a stepped-wedge evaluation.

The objective of this study was to evaluate whether providing antiretroviral therapy (ART) integrated in antenatal care clinics resulted in a greater proportion of treatment-eligible women initiating antiretroviral therapy during pregnancy compared with the existing approach of referral to antiretroviral therapy. The evaluation used a stepped-wedge design and included all HIV-infected, antiretroviral therapy-eligible pregnant women in eight public sector clinics in Lusaka district, Zambia. The main outcome indicators were the proportion of treatment-eligible women enrolling into HIV care while pregnant and within 60 days of HIV diagnosis and proportion initiating antiretroviral therapy during pregnancy. Adjusted odds ratios (AORs) and confidence intervals (CIs) for enrolment and initiation proportions were estimated through a logistic regression model accounting for clinical site cluster and time effects. Between 16 July 2007 and 31 July 2008, 13 917 women started antenatal care more than 60 days before the intervention rollout and constituted the control cohort; 17 619 started antenatal care after antiretroviral therapy integrated into antenatal care and constituted the intervention cohort. Of the 1566 patients found eligible for antiretroviral therapy, a greater proportion enrolled while pregnant and within the 60 days of HIV diagnosis in the intervention cohort (376/846, 44.4%) compared with the control cohort (181/716, 25.3%), adjusted odds ratio 2.06, 95% CI (1.27-3.34); and initiated antiretroviral therapy while pregnant in the intervention cohort (278/846, 32.9%) compared with the control cohort (103/716, 14.4%), adjusted odds ratio 2.01, 95% CI (1.37-2.95). An integrated antiretroviral therapy in antenatal care strategy doubled the proportion of treatment-eligible women initiating antiretroviral therapy while pregnant.

Editors’ note: This step-wedged evaluation design had all 8 participating clinics starting to collect data at the same time while providing the standard of care, i.e. referral to antiretroviral treatment services. Then one by one, each clinic crossed over to the intervention arm with antiretroviral services being provided in the antenatal care setting. This design allowed each clinic to act as its own control, providing patients to both arms, while also controlling for time trends by allowing comparisons across clinics at fixed points in time. Even though the treatment clinics were located on the same premises as the antenatal care clinics and local peer educators provided education and support to eligible women and offered to escort them to the treatment clinic, the percentage of treatment-eligible pregnant women initiating antiretroviral treatment more than doubled when antiretroviral treatment services were integrated into antenatal care. The lessons from this study can be applied to tuberculosis clinics and other services. Locating services together only goes so far in meeting patient needs and integration can make a big difference to uptake .