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ANC-HIV INTEGRATION Countdown to zero; i s it time for a gear shift?

ANC-HIV INTEGRATION Countdown to zero; i s 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.

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ANC-HIV INTEGRATION Countdown to zero; i s it time for a gear shift?

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  1. 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

  2. The promise of Integration… Integrating ANC and HIV services for pregnant women may result in….

  3. The reality of ANC & HIV integration Targets predominantly women and girls ignoring their male partners and the communities from which they hail from Can overburden already weak health systems in resource-limited settings by increasing the work load, leading to

  4. ...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

  5. ANC HIV INTEGRATION ANC MISSING GAP HIV Inadequate community engagement Inadequate male involvement Mothers who do not attend ANC STIGMA Barriers to optimal PMTCT uptake that occur outside healthcare settings seriously hamper efforts to eliminate MTCT

  6. 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.

  7. 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

  8. 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)

  9. 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

  10. 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.

  11. 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)

  12. 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

  13. 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

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