ANC-HIV INTEGRATIONCountdown to zero; is it time for a gear

shift? Dr Elizabeth Anne Bukusi,

MBChB, M.Med (ObGyn), MPH, PhD PGD (Research Ethics)Deputy Director Research and Training, KEMRI

Co-Director Research Care Training Program,(RCTP)Chief Research Officer

The promise of Integration…

better uptake of services,

more women receiving counseling

reduction of the time to treatment initiation

reduction of stigma

Better utilization of resources

Integrating ANC and HIV services for pregnant women may result in….

The reality of ANC & HIV integration

Can overburden already weak health systems in resource-limited settings by increasing the work load, leading to

Targets predominantly women and girls ignoring their male partners and the communities from which they hail from

poorer service delivery

poor sustainability of the integrated

services

high attrition rates along the PMTCT

cascade

...the reality of ANC & HIV integration

• Providers trained in PMTCT often move to better paying AIDS programs and thereby reduce already scarce human resources

• If integrated care is organized so as to provide separate consultation rooms for HIV positive women then in may be associated with increased levels of stigma

ANC HIV

MISSING GAP

Mothers who do not attend ANC

Inadequate community

engagement

Inadequate male

involvement

ANC HIV INTEGRATION

STIGMA

Barriers to optimal PMTCT uptake that occur outside healthcare settings seriously hamper efforts to eliminate MTCT

Case study: SHAIP study

The aim of the study was to test if a comprehensive integrated approach to ANC, PMTCT, and HIV care and treatment provision is an effective approach for district-wide implementation in Nyanza Province, Kenya.

OBJECTIVES

Specifically we assessed the impact of integrating PMTCT and HIV care and treatment in the antenatal care setting on HIV Vertical transmission rates, Maternal HIV treatment outcomes

(measured by change in CD4 count),Infant HIV testing uptake, Patient enrollment, retention and adherence

to HIV care

Results • Integration of HIV services into the ANC clinic was

not associated with a reduced risk of MTCT HIV infection at 9 months -AOR 0.89(95 %CI 0.56-

1.43)• There was no difference in maternal health outcomes

in integrated clinics compared to standard clinics• Maternal deaths AOR 1.20 (95 %CI 0.46-3.12)• Integration of HIV services into the ANC clinic

resulted in earlier initiation of HAART in eligible patients, however, no effect on retention into care

• Use of ARV during pregnancy AOR 3.5(95 %CI 1.73-7.23)

• Lost to Follow up AOR 0.74 ( 95% CI 0.38- 1.46)

Findings

• Providers: Supportive of integration and predicted benefits in terms of decrease patient time at the facility, increased efficiency, closer relationships, and better adherence

• Worried about increased workload and effects on disclosure of HIV status

Stigma is Related to Lower Uptake of Services

• Pregnant women who anticipated male partner stigma were more than twice as likely to refuse HIV testing, after adjusting for other predictors of HIV test refusal– Adjusted Odds Ratio=2.10, 95% CI: 1.15-3.85

• Pregnant women with higher perceptions of HIV-related stigma at baseline were half as likely to give birth in a health facility, after adjusting for other predictors of delivery in a health facility– Adjusted Odds Ratio=0.44, 95% CI: 0.22-0.88,

* Turan et al., AIDS & Behav, 2011.

* Turan et al., PLoS Medicine, 2012.

Self-Stigma as a Barrier to Enrollment in HIV Care & Treatment

• In stratified analyses adjusting for age, education, and having co-wives; women who experienced higher levels of internalized stigma had significantly lower odds of enrolling in HIV care and treatment at both integrated and non-integrated sites– At integrated sites (AOR= 0.49, 95% CI: 0.30-0.81)– At non-integrated sites (AOR=0.50, 95% CI: 0.31-0.79)

Gear Shift: “bridging” facilities and communities

Once women are enrolled in care, Facilities should be linked to community members more proactively to support adherence and retention e.g.– through accompaniment to appointments, – mobile phone messaging and – household-based contact tracing, are simple ways– Strategies targeting individuals within their families and

peer groups, e.g. • providing home-based and family HIV testing • training peer volunteers e.g. mentor mothers

Delivering the promises of integration: Myth or Realistic?

The promise of integration in elimination of MTCT can only be delivered if “integration efforts” deliberately involve, monitor, evaluate and strengthen community PMTCT activities