Structural Level Differences in the Mother-to-Child HIV Transmission Rate in South Africa: A Multilevel Assessment of Individual-, Health Facility-, and Provincial-Level Predictors of Infant HIV Transmission.
Structural Level Differences in the Mother-to-Child HIV Transmission Rate in South Africa: A Multilevel Assessment of Individual-, Health Facility-, and Provincial-Level Predictors of Infant HIV Transmission.
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DOI：
10.1097/qai.0000000000001289
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发表时间：
2017-04-15
期刊：
影响因子：
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通讯作者：
Goga AE
中科院分区：
文献类型：
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作者：
Woldesenbet SA;Jackson DJ;Lombard CJ;Dinh TH;Ramokolo V;Doherty T;Sherman GG;Pillay Y;Goga AE
2010 年，南非报告产后 4-8 周的早期母婴传播 (MTCT) 率为 3.5%。全省早期母婴传播率范围为 1.4% [95% 置信区间 (CI)：0.1 至 3.4] 至 5.9%（95% CI：3.8 至 8.0）。我们试图确定母婴传播率存在这些地理差异的原因。本研究使用来自 530 个机构的 2010 年南非母婴传播预防 (PMTCT) 评估 (SAPMTCTE) 数据进行多级建模。从产后 4-8 周的 3085 对母婴中收集了婴儿的访谈数据和血液样本。通过对设施工作人员的访谈收集了有关人力资源、转诊系统、护理联系和记录保存的设施级数据。省级数据是从公开数据中收集的（例如，每 10,000 人中的卫生专业人员）或从 SAPMTCTE（PMTCT 母婴抗逆转录病毒 (ARV) 覆盖率）中汇总到省级。报告了多级模型的方差分配系数和优势比（影响母婴传播的省级设施和个人层面的因素）。省级（5.0%）和设施级（1.4%）方差分配系数显示早期母婴传播没有实质性的地理差异。在考虑数据多层次性质的多变量分析中，以下因素与早期母婴传播相关：个体水平——母婴 ARV 摄入量低[调整后优势比 (AOR) = 2.5，95% CI：1.7 至 3.5]、混合母乳喂养（AOR = 1.9，95% CI：1.3 至 2.9）和母亲年龄 <20 岁（AOR 1.8， 95% CI：1.1 至 3.0）；机构层面——用于 HIV 检测服务的卫生保健人员不足（≤2）（AOR = 1.8，95% CI：1.1 至 3.0）；省级预防母婴传播抗逆转录病毒药物（母婴）覆盖率低于80%（AOR = 1.4，95% CI：1.1至1.9），每万人拥有卫生专业人员数量（AOR = 0.99，95% CI：0.98至0.99）。省级/机构级 MTCT 没有显着差异。这可能是由于在减少早期母婴传播方面的良好整体表现。人力资源分配（包括设施层面检测和护理的卫生保健人员分配不足）和预防母婴传播覆盖范围的差异影响了预防母婴传播计划的整体绩效。这些是影响护理质量的长期存在的系统性问题。
In 2010, South Africa reported an early mother-to-child transmission (MTCT) rate of 3.5% at 4–8 weeks postpartum. Provincial early MTCT rates ranged from 1.4% [95% confidence interval (CI): 0.1 to 3.4] to 5.9% (95% CI: 3.8 to 8.0). We sought to determine reasons for these geographic differences in MTCT rates. This study used multilevel modeling using 2010 South African prevention of mother-to-child transmission (PMTCT) evaluation (SAPMTCTE) data from 530 facilities. Interview data and blood samples of infants were collected from 3085 mother–infant pairs at 4–8 weeks postpartum. Facility-level data on human resources, referral systems, linkages to care, and record keeping were collected through facility staff interviews. Provincial level data were gathered from publicly available data (eg, health professionals per 10,000 population) or aggregated at province-level from the SAPMTCTE (PMTCT maternal-infant antiretroviral (ARV) coverage). Variance partition coefficients and odds ratios (for provincial facility- and individual-level factors influencing MTCT) from multilevel modeling are reported. The provincial- (5.0%) and facility-level (1.4%) variance partition coefficients showed no substantive geographic variation in early MTCT. In multivariable analysis accounting for the multilevel nature of the data, the following were associated with early MTCT: individual-level—low maternal–infant ARV uptake [adjusted odds ratio (AOR) = 2.5, 95% CI: 1.7 to 3.5], mixed breastfeeding (AOR = 1.9, 95% CI: 1.3 to 2.9) and maternal age <20 years (AOR 1.8, 95% CI: 1.1 to 3.0); facility-level–insufficient (≤2) health care-personnel for HIV-testing services (AOR = 1.8, 95% CI: 1.1 to 3.0); provincial-level PMTCT ARV (maternal–infant) coverage lower than 80% (AOR = 1.4, 95% CI: 1.1 to 1.9), and number of health professionals per 10,000 population (AOR = 0.99, 95% CI: 0.98 to 0.99). There was no substantial province-/facility-level MTCT difference. This could be due to good overall performance in reducing early MTCT. Disparities in human resource allocation (including allocation of insufficient health care personnel for testing and care at facility level) and PMTCT coverage influenced overall PMTCT programme performance. These are long-standing systemic problems that impact quality of care.