Closing the gaps in PMTCT program coverage, early infant diagnosis and treatment.

缩小预防母婴传播计划覆盖范围、婴儿早期诊断和治疗方面的差距。

• 批准号: 8434963
• 负责人: Mary-Ann Davies
• 金额: $ 45.5万
• 依托单位: UNIVERSITY OF CAPE TOWN
• 依托单位国家: 美国
• 财政年份: 2012
• 资助国家: 美国
• 起止时间: 2012-09-28 至 2013-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8434963
• 关键词: African; Anti-Retroviral Agents; Blood Tests; CD4 Lymphocyte Count; Caring; Child; Clinic; Clinical; Complement; Continuity of Patient Care; Country; Data; Diagnosis; Discipline of obstetrics; Drops; Effectiveness; Electronics; Ensure; Failure; Fostering; Future; Goals; Guidelines; HIV; HIV Seropositivity; Health Services; Health system; Individual; Infant; Infant Care; Intervention; Investigation; Laboratories; Link; Modeling; Monitor; Morbidity - disease rate; Mothers; Paper; Performance; Pharmaceutical Preparations; Pregnant Women; Prevalence; Prevention; Preventive; Primary Health Care; Protocols documentation; Provider; Province; Reporting; Services; South Africa; System; Technology; Test Result; Testing; Umbilical Cord Blood; Vertical Disease Transmission; Work; antiretroviral therapy; base; design; improved; infancy; mortality; pediatric human immunodeficiency virus; postnatal; prevent; programs; public health emergency; quality assurance; therapy design; transmission process; virtual

DESCRIPTION (provided by applicant): Virtual elimination of vertical transmission of HIV is within reach in South Africa. Despite high antenatal HIV prevalence, implementation of currently available technology and guidelines in the South African Prevention of Mother-to-Child Transmission (PMTCT) program, and particularly the longstanding and comprehensive program in the Western Cape Province, South Africa, has resulted in substantial reductions in vertically transmitted HIV to 3.5% across the country, and 3.3% in the Western Cape. Yet, elimination remains elusive due to persistent coverage gaps and drop-offs at each of the steps required in completion of the PMTCT and infant care continuum, with upwards of 1000 vertically infected infants born in the Western Cape each year. Improving the performance of the current PMTCT and antiretroviral therapy (ART) guidelines at each point in the care continuum through meticulous surveillance of system failures with resultant intervention, are key to further mitigating the effect of HIV on children, irrespective of possible future introduction of different guideline and service design options. Strengthening the health system with this active surveillance approach will provide long term benefits that will both complement and endure beyond future changes in drug protocols or service delivery models. This system will foster a paradigm in which identified cases of infant HIV exposure not covered by PMTCT drugs and HIV infected infants are viewed as a public health emergency requiring urgent intervention to identify reasons for program failure and mitigate its effects in an individual child. This project focused on a primary care obstetric facility, aims to implement and evaluate three linked enhancements to the existing service platform that will iteratively identify and close all PMTCT and early infant diagnosis and ART coverage gaps. First, existing paper registers at antenatal, obstetric and infant clinics will be digitized, internally linked, and merged with laboratory data using context-appropriate technology that has been applied to other priority programs, namely ART and TB monitoring. The combined PMTCT e-register will be linked to a system of urgent reporting of laboratory results of low CD4 counts in pregnant women and positive infant HIV-PCR test results to clinics, with tracing to ensure prompt ART initiation. This will strengthen the health system to close these key PMTCT coverage gaps. Second, a system of routine cord blood testing for HIV, and, if positive, the presence of antiretroviral drugs (ARVs) will identify and link to care HIV-exposed infants with no/suboptimal peripartum ARVs to ensure interventions to prevent postnatal transmission, prompt infant diagnosis and ART if infected. Third, a program of clinical quality assurance, improvement and audit will be established. This will be based on data from both the e-register and cord blood surveillance that will generate an early warning system of coverage gaps. Using these data, PMTCT program failures will be regularly and systematically analyzed together with Provincial and Local Departments of Health service managers and providers, with a view to achieving iterative service improvements. PUBLIC HEALTH RELEVANCE: Virtual elimination of pediatric HIV, the leading cause of under 5 mortality in South Africa, is possible with current PMTCT technology and guidelines, but remains elusive due to persistent coverage gaps and missed opportunities for PMTCT, despite a longstanding and comprehensive program. Systems to strengthen and enhance the effectiveness of health service implementation of PMTCT are therefore needed. The goal of this project is to implement and evaluate a replicable active surveillance system integrated with the existing monitoring platform that aims to (i) provide an early warning system of PMTCT coverage gaps leading to iterative program performance improvements and (ii) identify and link to care pregnant women and HIV exposed and infected infants critically needing ART or interventions to prevent transmission, thus closing key gaps in the PMTCT continuum.

描述（由申请人提供）：实际上消除艾滋病毒的垂直传播在南非是可以实现的。尽管产前艾滋病毒流行率很高，但在南非预防母婴传播方案中实施现有技术和指导方针，特别是在南非西开普省实施长期综合方案，已使全国垂直传播艾滋病毒的比例大幅下降至3.5%，西开普省为3.3%。然而，由于在完成防止母婴传播和婴儿护理连续体所需的每一个步骤中持续存在的覆盖差距和下降，消除仍然难以实现，每年在西开普省出生的垂直感染婴儿超过1 000名。无论今后是否可能采用不同的指导方针和服务设计方案，通过对系统故障进行细致监测并采取相应的干预措施，在护理连续体的每一个环节改进现行防止母婴传播和抗逆转录病毒疗法指导方针的执行情况，是进一步减轻艾滋病毒对儿童影响的关键。通过这种积极的监测方法加强卫生系统将提供长期的好处，这些好处将补充并持续到药物协议或服务提供模式的未来变化之后。这一系统将促进一种模式，在这种模式中，已确定的婴儿艾滋病毒暴露病例不包括在预防母婴传播药物和艾滋病毒感染的婴儿被视为公共卫生紧急情况，需要紧急干预，以确定方案失败的原因，并减轻其对个别儿童的影响。 该项目侧重于一个初级保健产科设施，旨在实施和评估现有服务平台的三项相关增强措施，这些措施将反复查明和填补所有防止母婴传播和婴儿早期诊断以及抗逆转录病毒疗法覆盖面的差距。首先，产前、产科和婴儿诊所现有的纸质登记册将被数字化，内部链接，并使用已应用于其他优先项目（即抗逆转录病毒疗法和结核病监测）的适合背景的技术与实验室数据合并。防止母婴传播综合电子登记册将与一个向诊所紧急报告孕妇CD 4细胞计数低的实验室结果和婴儿艾滋病毒聚合酶链反应阳性检测结果的系统挂钩，并进行追踪，以确保及时开始抗逆转录病毒治疗。这将加强 卫生系统缩小这些关键的预防母婴传播覆盖差距。第二，建立一个常规的脐带血艾滋病毒检测系统，如果检测结果呈阳性，将通过抗逆转录病毒药物（ARV）的存在来确定 并将护理接触艾滋病毒的婴儿与无抗逆转录病毒药物/未达到最佳效果的围产期抗逆转录病毒药物联系起来，以确保采取干预措施，预防产后传播，及时进行婴儿诊断，并在受感染时进行抗逆转录病毒治疗。第三，建立临床质量保证、改进和审核程序。这将基于电子登记和脐带血监测的数据，这将产生一个覆盖率差距的预警系统。利用这些数据，将与省和地方卫生部门的服务管理人员和提供者一起定期和系统地分析预防母婴传播方案的失败，以期实现反复的服务改进。 公共卫生关系：儿童艾滋病毒是南非5岁以下儿童死亡的主要原因，通过目前的预防母婴传播技术和指导方针，实际消除儿童艾滋病毒是可能的，但由于持续的覆盖差距和错过预防母婴传播的机会，尽管有长期和全面的计划，仍然难以实现。因此，需要建立制度，加强和提高预防母婴传播保健服务的有效性。该项目的目标是实施和评估一个与现有监测平台相结合的可复制的主动监测系统，其目的是（一）提供一个预防母婴传播覆盖率差距的预警系统，从而导致迭代方案绩效的改进，以及（二）确定并联系到急需抗逆转录病毒疗法或干预措施以预防传播的孕妇和艾滋病毒暴露和感染婴儿，从而填补了预防母婴传播连续体中的关键空白。