Conditional cash transfers to increase uptake of and retention of PMTCT services

描述(申请人提供)：如果执行得当，世界卫生组织最近的建议可以将母乳喂养人群中母婴传播艾滋病毒(MTCT)的风险降低到5%以下，在非母乳喂养人群中降低到2%以下。成功实施预防母婴传播艾滋病毒(母婴传播)干预措施，最大限度地提高产妇健康和婴儿无艾滋病毒存活率，需要高水平(95%)的接受和遵守一系列服务，也称为母婴传播级联。大幅提高对防止母婴传播级联的接受和遵守程度的干预措施，对于实现到2015年基本消除母婴传播的全球目标至关重要。在过去的十年里，有条件现金转移(CCT)已经成为一种广泛使用的干预措施，以实现行为改变，但它们还没有被应用于预防母婴传播环境，对有条件现金转移促进健康促进行为的机制知之甚少。这项研究的目的是：1)测试小额、增加对艾滋病毒感染孕妇的现金支付，条件是她们参加所有预定的诊所就诊和接受服务，是否会增加接受最有效的抗逆转录病毒(ARV)方案并在附属产妇分娩的妇女的比例，以及2)确定：a)促进或抑制接受和遵守预防母婴传播服务的因素，包括艾滋病毒感染孕妇对母婴传播风险和艾滋病毒感染对婴儿健康的潜在影响的严重程度的认知；以及b)防止母婴传播方案在多大程度上减轻了对防止母婴传播的吸收和遵守的障碍。这项研究将在我们由PEPFAR/CDC资助的刚果民主共和国金沙萨艾滋病毒预防、护理和治疗项目中进行，该项目包括预防母婴传播网络，由44名孕妇组成，为50,000多名孕妇提供服务。在怀孕28到32周之间的第一次访问中，600名新诊断的艾滋病毒阳性孕妇将被随机分为：1)护理标准，或2)护理标准加上增加的现金支付，从5美元开始，每月增加1美元，直到产后6周。如果母亲未能完成特定就诊所需的任何行动，包括：参加每月预定的诊所就诊、提供血液样本进行CD4计数、接受艾滋病毒护理和治疗(如果被转介)，以及坚持使用处方的抗逆转录病毒药物，则将出现重置应急措施，即逐步增加的激励价值恢复到其原值(5美元)。这项研究将通过国家艾滋病控制计划(PNLS)、天主教医学委员会(BDOM)、刚果救世军和金沙萨公共卫生学校与刚果民主共和国卫生部合作进行。在刚果民主共和国，我们的成果将为PEPFAR和刚果民主共和国政府正在进行的努力提供信息，以实现到2015年基本消除儿童艾滋病毒的目标。如果被证明是有效的，我们提出的应急管理方案可以很容易地整合到整个低收入和中等收入国家的其他防止母婴传播方案中。 公共卫生相关性：为了向正在进行的关于如何确保感染艾滋病毒的孕妇及其婴儿获得预防母婴传播(PMTCT)的重要服务的辩论提供信息，我们将测试一项不断升级的小额、有条件现金转移(CCT)计划的有效性，以增加患者留存和服务吸收。此外，我们将研究艾滋病毒感染妇女如何处理她们在产前护理访问中收到的信息，以及她们如何感知垂直传播风险，以更好地了解有条件现金转移如何影响对护理的坚持。如果被证明是有效的，我们提出的低成本有条件现金援助可以很容易地整合到其他低收入和中等收入国家的防止母婴传播计划中。

DESCRIPTION (provided by applicant): If implemented optimally, recent World Health Organization recommendations can reduce the risk of mother- to-child HIV transmission (MTCT) to less than 5% in breastfeeding populations and less than 2% in non- breastfeeding populations. Successful implementation of prevention of mother-to-child HIV transmission (PMTCT) interventions that maximize maternal health and infant HIV-free survival requires high levels (>95%) of uptake and adherence to a continuum of services also referred to as the PMTCT cascade. Interventions that substantially improve uptake and adherence to the PMTCT cascade are critical for reaching the global goal of virtual elimination of MTCT by 2015. In the past decade, conditional cash transfers (CCTs) have become a widely-used intervention for achieving behavior change, but they have not been applied to the PMTCT setting and little is known about the mechanisms through which CCTs facilitate the adoption of health promoting behaviors. The aims of this study are 1) to test whether small, increasing cash payments to HIV- infected pregnant women, on the condition that they attend all scheduled clinic visits and uptake of services, will increase the proportion of women who receive the most effective antiretroviral (ARV) regimen they are eligible for and deliver at an affiliated maternity, and 2) identify: a) factors that facilitate or inhibit uptake and adherence to PMTCT services, including HIV-infected pregnant women's perception of MTCT risk and the severity of the potential impact of HIV infection on their infants' health; and b) the extent to which identified barriers to PMTCT uptake and adherence were mitigated by the CCT program. The study will be conducted in our PEPFAR/CDC-funded HIV prevention, care, and treatment program in Kinshasa, Democratic Republic of Congo (DRC) which include for PMTCT, a network of 44 maternities, and serving over 50,000 pregnant women. At their first visit between 28 and 32 weeks of gestation, 600, newly diagnosed, HIV-positive pregnant women will be randomized to: 1) the standard of care, or 2) the standard of care plus increasing cash payments, starting at $5 and increasing by $1 each month, trough six-week postpartum. There will be a reset contingency wherein the escalating value of the incentive goes back to its original value ($5) should the mother fail to complete any of the actions required at a specific visit including: attending the monthly scheduled clinic visits, providing a blood sample for CD4 count, uptake of HIV care and treatment if referred, and adhere to prescribed antiretroviral drugs. The study will be conducted in partnership with the DRC Ministry of Health through the national AIDS control program (PNLS), the Catholic Medical Board (BDOM), the DRC Salvation Army, and the Kinshasa School of Public Health. In the DRC, our results will inform the ongoing effort by PEPFAR and the DRC government towards the goal of virtual elimination of pediatric HIV by 2015. If shown to be effective, the contingency management scheme we propose can be easily integrated into other PMTCT programs throughout low and middle income countries. PUBLIC HEALTH RELEVANCE: To inform the ongoing debate over how to ensure that pregnant HIV-infected women and their infants receive vital services for the prevention of mother-to-child HIV transmission (PMTCT), we will test the effectiveness of an escalating scheme of small, conditional cash transfers (CCTs) to increase patient retention and service uptake. Additionally, we will examine how HIV-infected women process information they receive during antenatal care visits and how they perceive vertical transmission risk, in order to better understand how CCTs affect adherence to care. If shown to be effective, the low-cost CCTs we propose can be easily integrated in PMTCT programs throughout other low- and middle-income countries.