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）：南非已经可以实际消除艾滋病毒的垂直传播。尽管产前艾滋病毒感染率很高，但南非预防母婴传播 (PMTCT) 计划中现有技术和指南的实施，特别是南非西开普省的长期综合计划，已使全国艾滋病毒垂直传播率大幅下降至 3.5%，西开普省则降至 3.3%。然而，由于持续的覆盖差距以及完成预防母婴传播和婴儿护理连续体所需的每个步骤的持续下降，消除仍然难以实现，每年有超过 1000 名垂直感染婴儿在西开普省出生。无论未来可能引入不同的指南和服务设计方案，通过对系统故障进行细致监测并进行干预，提高当前预防母婴传播和抗逆转录病毒治疗 (ART) 指南在护理连续体各个阶段的表现，是进一步减轻艾滋病毒对儿童影响的关键。通过这种主动监测方法加强卫生系统将带来长期效益，这些效益将补充并持续超越未来药物方案或服务提供模式的变化。该系统将培育一种范式，将已发现的预防母婴传播药物未涵盖的婴儿艾滋病毒暴露病例和感染艾滋病毒的婴儿视为突发公共卫生事件，需要紧急干预，以确定计划失败的原因并减轻其对个别儿童的影响。 该项目重点关注初级保健产科设施，旨在实施和评估现有服务平台的三项相关增强功能，这些增强功能将迭代确定并弥补所有 PMTCT 和早期婴儿诊断以及 ART 覆盖范围的差距。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。合并的 PMTCT 电子登记系统将与一个向诊所紧急报告孕妇 CD4 计数低的实验室结果和婴儿 HIV-PCR 检测结果呈阳性的系统相连，并进行追踪以确保及时启动 ART。这将加强 卫生系统缩小这些关键的预防母婴传播覆盖范围的差距。其次，常规脐带血 HIV 检测系统，如果呈阳性，则抗逆转录病毒药物 (ARV) 的存在将确定 并与未使用/未使用围产期抗逆转录病毒药物治疗的艾滋病毒暴露婴儿联系起来，以确保采取干预措施，防止产后传播、及时诊断婴儿并在感染时进行抗逆转录病毒治疗。第三，建立临床质量保证、改进和审核计划。这将基于电子登记和脐带血监测的数据，这将生成覆盖范围差距的早期预警系统。利用这些数据，将与省和地方卫生部门的服务管理者和提供者一起定期、系统地分析预防母婴传播项目的失败，以期实现服务的迭代改进。 公共卫生相关性：利用当前的 PMTCT 技术和指南，几乎可以消除儿童艾滋病毒（南非 5 岁以下儿童死亡的主要原因），但由于持续的覆盖范围差距和错失 PMTCT 机会，尽管有长期且全面的计划，但由于持续存在的覆盖差距和错过的 PMTCT 机会，仍然难以实现。因此，需要建立加强和提高预防母婴传播卫生服务实施有效性的系统。该项目的目标是实施和评估与现有监测平台集成的可复制主动监测系统，旨在（i）提供 PMTCT 覆盖差距的早期预警系统，从而提高迭代计划绩效；（ii）识别并联系护理孕妇以及艾滋病毒暴露和感染的婴儿，这些婴儿急需 ART 或干预措施以防止传播，从而缩小 PMTCT 连续体中的关键差距。