Addressing adherence to PMTCT and early care of women and infants in South Africa

描述（由申请人提供）：本研究的总体目标是通过试点和进一步开发旨在解决艾滋病毒感染妇女及其子女坚持预防母婴传播和早期护理的干预措施，提高资源有限国家预防母婴传播（PMTCT）方案的有效性。现在人们普遍认识到，世界各地建立的许多防止母婴传播方案在预防儿童感染艾滋病毒方面没有取得最佳效果，也没有发挥其作为照顾感染艾滋病毒的妇女及其子女的切入点的潜力。预防母婴传播计划的成功需要坚持许多不同的活动：例如，妊娠早期CD 4计数的表现和婴儿安全喂养的维持。本研究采用基于社会生态学理论的干预方法，通过影响参与者（管理人员、工作人员和患者）的行为，提高对PMTCT多个组成部分的依从性，从而实现医疗保健系统的结构性变化，并改变个人的行为。本研究的目的是：1.在南非一个由11个产前诊所和3家医院组成的单一保健分区实施干预措施，并评估干预措施在多大程度上改善了预防母婴传播的不同组成部分，方法是利用现有的卫生部门数据，检查坚持预防母婴传播的标志物随时间的变化（即儿童接受CD 4检测和PCR检测的比例）。2.进行定性评价，以评估干预措施的可接受性和可行性，并确定阻碍或促进实施的因素。3.进行定量评价，以检查预防母婴传播所涉每项活动的变化程度，查明具有中介作用的变量，并确定干预措施在多大程度上改变了这些变量。这将通过分析从两个不同的艾滋病毒阳性妇女群体获得的数据来完成-第一个群体将在实施干预措施之前接受产前护理，第二个群体将是在实施干预措施之后接受产前护理的妇女。艾滋病毒阳性妇女将在分娩时登记，并将在三个月后的后续访谈中获得关于坚持预防母婴传播的数据。访谈将包括关于护理依从性的信息以及可能有助于依从性的因素（例如：披露艾滋病毒状况和医患关系的质量）。将进行定量分析，以确定与预防母婴传播相关活动的差异，并确定对改善结果具有中介作用的变量。定性评价将有助于进一步发展干预措施。这项研究完成后，将更广泛地实施干预措施，评估其效果，并努力确保广泛传播。公共卫生相关性：在资源有限的国家，预防母婴传播艾滋病毒和确保感染艾滋病毒的妇女及其子女得到适当照顾的努力目前没有充分发挥潜力。这项研究的目标是进一步制定一项干预措施，以改善怀孕和分娩后感染艾滋病毒的妇女对护理的坚持。随着今后对这一干预措施的有效性的证明和进一步的传播，这项研究中制定的干预措施可能对改善感染艾滋病毒的妇女及其子女的健康产生重大影响，并防止婴儿早期死亡率高。

DESCRIPTION (provided by applicant): The overall goal of this study is to improve the effectiveness of programs to prevent mother-to-child HIV transmission (PMTCT) in resource-limited countries through the piloting and further development of an intervention aimed at addressing adherence to PMTCT and early care of HIV-infected women and their children. It is now well recognized that the many PMTCT programs that have been established worldwide are not performing optimally in preventing HIV infection among children and have failed in their potential to be entry points for care for HIV-infected women and their children. The success of a PMTCT program requires adherence to many different activities: e.g., performance of a CD4 count in early pregnancy and maintenance of safe infant feeding. This research uses an intervention that is based in social-ecological theory and uses participatory methods to improve adherence to the multiple components of PMTCT by affecting the behaviors of the participants (administrators, staff and patients) so as to bring about structural changes in the health care system and change the behaviors of individuals. The aims of the study are to: 1. Implement the intervention in a single health care sub-district in South Africa comprised of 11 antenatal clinics and three hospitals and assess the extent to which the intervention improves different components of PMTCT by using readily available health department data to examine changes over time in markers of adherence to PMTCT (i.e. proportion with CD4 tests and PCR testing of children). 2. Conduct a qualitative evaluation to assess the acceptability and feasibility of the intervention and identify factors that either impede or facilitate implementation. 3. Conduct a quantitative evaluation to examine the extent to which there is change in each of the activities involved in PMTCT, identify variables that have a mediating effect and determine to what extent these are modified by the intervention. This will be done by analyzing data obtained from two different cohorts of HIV positive women -- the first will have received their antenatal care prior to implementation of the intervention, and the second cohort will be women attending antenatal care after the intervention has been introduced. HIV positive women will be enrolled at the time of delivery and data on adherence to PMTCT will be obtained in follow-up interviews at three months. The interviews will include information on adherence to care and factors that might contribute to adherence (e.g.: disclosure of HIV status and quality of the patient-provider relationship). Quantitative analyses will be performed to determine differences in PMCTC-related activities and identify variables that have a mediating effect on improving outcomes. The qualitative evaluation will contribute to further development of the intervention. Following completion of this study, the intervention will be implemented more widely, its effectiveness assessed, and efforts made to ensure widespread dissemination. PUBLIC HEALTH RELEVANCE: In limited-resource countries efforts to prevent mother-to-child transmission of HIV and ensure appropriate care for HIV-infected women and their children presently fall short of their potential. The goal of this research is to further develop an intervention to improve adherence to care for HIV-infected women in pregnancy and post- delivery. With future demonstration of the efficacy of this intervention and further dissemination, the intervention developed in this research could have a substantial impact on improving the health of HIV-infected women and their children and prevent high rates of death in early infancy.