Health systems imperfections continue to lead to preventable HIV vertical transmission in many countries. In sub-Saharan Africa ~4% women are newly infected during the pregnancy or breastfeeding (PBF) period, accounting for ~37% PBF women with viral loads (VL) >1000 copies/mL. VL and repeat HIV testing are key processes in ensuring prevention of mother-to-child transmission (PMTCT) success and maternal health. We test the effectiveness of quality improvement (QI) in increasing VL and repeat HIV testing in PMTCT in rural South Africa.
The MONARCH stepped-wedge randomised trial (NCT02626351) of a QI intervention was conducted at seven primary health care clinics in a rural community of northern KwaZulu-Natal, South Africa, from July 2015-January 2017. All women aged ≥18 years who delivered during the study were eligible for enrollment. We performed intent-to-treat analyses using Poisson mixed effects hierarchical models, with time fixed effects and clinic random effects. Extracted from routine antenatal medical records, our two pre-registered primary endpoints were: (i) proportion of HIV-positive pregnant women with an up-to-date (within the past 90 days) VL test; (ii) proportion of HIV-negative pregnant women with an up-to-date repeat HIV test.
We report preliminary results. Of 2162 study participants, 54% were exposed to the intervention. Median age was 25 years (interquartile range [IQR] 21-30); median gestational age at first booking was 19 weeks (IQR 15-24); median parity was 1 (IQR 0-2). Overall HIV prevalence was 47% (95% confidence interval [CI] 45-50%): prevalence was highest amongst 30-34 year-olds (70%, 95%CI 65-75%). The proportion of HIV-positive pregnant women (n=1026) receiving VL tests and HIV-negative pregnant women (n=1136) receiving repeat HIV tests increased over calendar time. The QI intervention significantly increased VL testing (risk ratio (RR) 1.26, 95%CI 1.06-1.49, p=0.01), but did not increase repeat HIV testing (RR 1.13, 95%CI 0.96-1.33, p=0.13).
QI led to improvement in VL testing in PMTCT in this rural community in South Africa. This intervention holds promise for improving HIV VL control during pregnancy, helping eliminate mother-to-child HIV transmission and improve maternal health, by strengthening essential antenatal and HIV clinical processes. Future research should identify mechanisms of action to explain differential effects on endpoints.