©Elizabeth Glaser Pediatric AIDS Foundation

The issue
The success of prevention of mother-to-child transmission (PMTCT) programs depends on HIV-positive women’s ability and willingness to initiate and/or continue lifelong antiretroviral therapy (ART), and HIV-negative women’s uptake of preventive behaviors. Pregnant and postpartum HIV-positive women face a particularly complex set of barriers to PMTCT uptake at the policy, health facility, community, and individual levels. They are vulnerable to poor retention in care and adherence to treatment, especially in the first three months after ART initiation and postpartum. In addition, counseling and support for primary prevention among HIV-negative pregnant women is almost non-existent in most PMTCT programs.

Our approach
Project SOAR is implementing and evaluating IMPROVE—a multidisciplinary integrated management team intervention to increase maternal and child health (MCH) and HIV services uptake and retention in Lesotho. In the IMPROVE intervention, multidisciplinary integrated management teams (1) coordinate patient-focused and outcome-oriented PMTCT and MCH services; (2) receive enhanced counseling and skills-building training and job aids; and (3) provide early community-based counseling and support for HIV-positive women to minimize loss to follow-up. The study is a cluster randomized design with 12 facilities randomized to receive the IMPROVE intervention or the national standard of care. SOAR is enrolling a cohort of HIV-positive and HIV-negative pregnant women and prospectively following them every three months through pregnancy and until their child reaches 24 months of age. The primary objective is to evaluate the effect of the intervention on retention in HIV care, viral suppression, adherence to ART in HIV-positive women, and HIV retesting in HIV-negative women. In addition, qualitative interviews are being conducted with study women, healthcare workers, and village health workers to evaluate the feasibility and acceptability of integrating this intervention into routine national systems of care. Finally, a sub-study is determining the cost-effectiveness of the IMPROVE intervention in achieving positive health outcomes among pregnant/postpartum women and their infants.

The impact
This study builds on existing MCH/PMTCT staffing and infrastructure to optimize service quality and efficiency, and maximize program effectiveness. The interventions and tools can be readily incorporated into other similar types of clinical and community services or country settings.