Paper: Linking women who test HIV‐positive in pregnancy‐related services to long‐term HIV care and treatment services: a systematic review

Reference:

Laura, F., Alison D., G., Deborah, W.-J., Tanya, K., John O., O., & David A., R. (2012). Linking women who test HIV-positive in pregnancy-related services to long-term HIV care and treatment services: a systematic review. Tropical Medicine & International Health, (5), 564. https://doi-org.ezproxy.aut.ac.nz/10.1111/j.1365-3156.2012.02958.x

Abstract

OBJECTIVES: To quantify attrition between women testing HIV-positive in pregnancy-related services and accessing long-term HIV care and treatment services in low- or middle-income countries and to explore the reasons underlying client drop-out by synthesising current literature on this topic.

METHODS: A systematic search in Medline, EMBASE, Global Health and the International Bibliography of the Social Sciences of literature published 2000–2010. Only studies meeting pre-defined quality criteria were included. RESULTS: Of 2543 articles retrieved, 20 met the inclusion criteria. Sixteen (80%) drew on data from sub-Saharan Africa. The pathway between testing HIV-positive in pregnancy-related services and accessing long-term HIV-related services is complex, and attrition was usually high. There was a failure to initiate highly active antiretroviral therapy (HAART) among 38–88% of known-eligible women. Providing ‘family-focused care’, and integrating CD4 testing and HAART provision into prevention of mother-to-child HIV transmission services appear promising for increasing womenʼs uptake of HIV-related services. Individual-level factors that need to be addressed include financial constraints and fear of stigma.

CONCLUSIONS: Too few women negotiate the many steps between testing HIV-positive in pregnancy-related services and accessing HIV-related services for themselves. Recent efforts to stem patient drop-out, such as the MTCT-Plus Initiative, hold promise. Addressing barriers and enabling factors both within health facilities and at the levels of the individual woman, her family and society will be essential to improve the uptake of services.

Conclusion

This review provides strong evidence that, in most settings that have been studied to date in LMICs (Low and Middle Income Countries) , relatively few women successfully negotiate the many steps between testing HIV-positive in pregnancy-related services andaccessing HIV services for themselves. Improving this willrequire attention to barriers and enabling factors both within health facilities and at the level of the individual woman and her wider family and society. Box 2 lists health facility-level interventions recommended for improving

linkage into HIV care and treatment services from HIV testing in pregnancy-related services.

Additional work is needed to better understand the effectiveness and sustainability of these interventions in varied settings. It is critical that the strengths and weaknesses of existing and new interventions be documented so that lessons learnt can be translated into concrete benefits in terms of access to HIV-related services for the pregnant women who require them

Box 2

Health facility-level interventions to improve linkage between HIV testing in pregnancy-related services and long-term HIV care and treatment services

• Introduction into post-test counselling of messages on the importance of assessment for and, if eligible, initiation of HAART both for PMTCT and for women’s health.

• Point of care CD4 count testing with in-session results available within pregnancy-related services.

• Full integration of HIV care and treatment services into ANC services (where infrastructure and staffing allow) with CD4 count testing and HAART initiation available daily, and women’s transition to the HIV clinic weeks⁄months post-partum.

•Improved linkages between HIV testing in delivery and PNC services to HIV care and treatment services (whether in ANC or a separate HIV clinic).

• Provision of family-focused care, including, at a minimum, the offer of counselling, testing, treatment and psychosocial support for women’s partner and children and other household members. Ideally, this would also include: male involvement in PMTCT and pregnancy-related counselling e.g. infant feeding counselling; accessing to reproductive health and

family planning services; screening for intimate partner violence; nutrition counselling; attention to mental health issues; and attention to early child-hood development.

•Peer support for women newly diagnosed with HIV, including escorts to the HIV clinic if these services are not available within the ANC setting.

•Improved health information systems that enable tracking of patients between hospital departments (and, ideally, across health facilities).

•Institution of communication systems that allow tracing of patients lost to follow-up.

•Incentives to attend the hospital e.g. transport subsidies, food supplements etc.

x