Impact of a Systems Engineering Intervention on PMTCT Service Delivery in Cote d'Ivoire, Kenya, Mozambique: A Cluster Randomized Trial
Impact of a Systems Engineering Intervention on PMTCT Service Delivery in Cote d'Ivoire, Kenya, Mozambique: A Cluster Randomized Trial
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DOI：
10.1097/qai.0000000000001023
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发表时间：
2016-07-01
影响因子：
3.6
通讯作者：
Sherr, Kenneth
中科院分区：
文献类型：
--
作者：
Rustagi, Alison Silvis;Gimbel, Sarah;Sherr, Kenneth
背景：预防艾滋病毒母婴传播（PMTCT）的有效干预措施尚未很好地转化为有效的项目。先前对系统工程应用于 PMTCT 的研究缺乏比较组或随机化。方法：科特迪瓦、肯尼亚和莫桑比克的 36 个卫生机构被随机分配到常规护理或系统工程干预组，按国家和数量分层。干预措施指导设施工作人员反复识别并纠正 PMTCT 实施的障碍。登记数据量化了首次产前护理期间的 HIV 检测、HIV 阳性孕妇的抗逆转录病毒药物 (ARV) 以及 6-8 周内 HIV 暴露婴儿 (HEI) 的 HIV 筛查覆盖率。我们使用 t 检验比较了基线（2013 年 1 月至 2014 年 1 月）和干预后（2015 年 1 月至 2015 年 3 月）期间的变化。所有分析均为意向性治疗。 结果：ARV 覆盖率增加 3 倍 [干预组 +13.3%（95% CI：0.5 至 26.0），对照设施 +4.1（-12.6 至 20.7）]，HEI 筛查增加 17 倍 [干预组 +11.6（-2.6 至 25.7），对照组 +0.7（-12.9 至 20.7）] 14.4）控制设施]。在预先指定的亚组分析中，肯尼亚的抗逆转录病毒药物覆盖率显着增加[干预组为+20.9（-3.1至44.9），对照组为-21.2（-52.7至10.4）； P = 0.02]。莫桑比克的 HEI 筛查显着增加 [干预组为 +23.1（10.3 至 35.8），而对照组为 +3.7（-13.1 至 20.6）； P = 0.04]。 HIV 检测在各组之间没有显着差异。结论：在这项旨在改善 PMTCT 的系统工程的首次随机试验中，我们发现与对照组相比，干预设施中的 ARV 覆盖率和 HEI 筛查有了显着更大的改善，这在预先指定的亚组中非常显着。系统工程可以加强预防母婴传播服务的提供并保护婴儿免受艾滋病毒感染。
Background: Efficacious interventions to prevent mother-to-child HIV transmission (PMTCT) have not translated well into effective programs. Previous studies of systems engineering applications to PMTCT lacked comparison groups or randomization.Methods: Thirty-six health facilities in Cote d'Ivoire, Kenya, and Mozambique were randomized to usual care or a systems engineering intervention, stratified by country and volume. The intervention guided facility staff to iteratively identify and then rectify barriers to PMTCT implementation. Registry data quantified coverage of HIV testing during first antenatal care visit, antiretrovirals (ARVs) for HIV-positive pregnant women, and screening HIV-exposed infants (HEI) for HIV by 6-8 weeks. We compared the change between baseline (January 2013-January 2014) and postintervention (January 2015-March 2015) periods using t-tests. All analyses were intent-to-treat.Results: ARV coverage increased 3-fold [+13.3% points (95% CI: 0.5 to 26.0) in intervention vs. +4.1 (-12.6 to 20.7) in control facilities] and HEI screening increased 17-fold [+11.6 (-2.6 to 25.7) in intervention vs. +0.7 (-12.9 to 14.4) in control facilities]. In prespecified subgroup analyses, ARV coverage increased significantly in Kenya [+20.9 (-3.1 to 44.9) in intervention vs. -21.2 (-52.7 to 10.4) in controls; P = 0.02]. HEI screening increased significantly in Mozambique [+23.1 (10.3 to 35.8) in intervention vs. +3.7 (-13.1 to 20.6) in controls; P = 0.04]. HIV testing did not differ significantly between arms.Conclusions: In this first randomized trial of systems engineering to improve PMTCT, we saw substantially larger improvements in ARV coverage and HEI screening in intervention facilities compared with controls, which were significant in prespecified subgroups. Systems engineering could strengthen PMTCT service delivery and protect infants from HIV.