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

描述（由申请人提供）：如果得到最佳实施，世界卫生组织最近的建议可以将母乳喂养人群的母婴艾滋病毒传播（MTCT）风险降低到5%以下，非母乳喂养人群的风险降低到2%以下。要成功实施预防母婴传播艾滋病毒干预措施，最大限度地提高孕产妇健康和婴儿无艾滋病毒存活率，就需要高水平（>95%）的接受和坚持一系列服务，也称为预防母婴传播级联服务。大幅度提高预防母婴传播级联方案的接受率和坚持率的干预措施，对于实现到2015年基本消除母婴传播的全球目标至关重要。在过去的十年中，有条件的现金转移支付（CCT）已成为一种广泛使用的干预措施，以实现行为改变，但他们还没有被应用到PMTCT设置和鲜为人知的机制，通过CCT促进健康促进行为的采用。这项研究的目的是：（1）测试向感染艾滋病毒的孕妇支付小额、不断增加的现金，条件是她们参加所有预定的诊所就诊和接受服务，是否会增加有资格接受最有效的抗逆转录病毒治疗并在附属产科分娩的妇女的比例，以及（2）确定：（a）促进或抑制接受和坚持预防母婴传播服务的因素，包括感染艾滋病毒的孕妇对母婴传播风险的认识以及艾滋病毒感染对其婴儿健康的潜在影响的严重性;和B）持续性艾滋病治疗项目在多大程度上缓解了已识别的PMTCT吸收和依从性障碍。这项研究将在我们的PEPFAR/CDC资助的艾滋病毒预防、护理和治疗项目中进行，该项目位于刚果民主共和国（DRC）的金沙萨，其中包括一个由44个产科医院组成的网络，为50，000多名孕妇提供服务。在怀孕28至32周之间的首次就诊时，600名新诊断的艾滋病毒阳性孕妇将被随机分配到：1）标准护理，或2）标准护理加增加现金支付，从5美元开始，每月增加1美元，产后6周。如果母亲未能完成特定访视所需的任何行动，包括：参加每月预定的诊所访视，提供血液样本进行CD 4计数，接受艾滋病毒护理和治疗（如果转诊），并坚持使用处方抗逆转录病毒药物，则将重置应急措施，其中奖励的递增价值将恢复到其原始价值（5美元）。这项研究将通过国家艾滋病控制计划（PNLS）与刚果民主共和国卫生部合作，天主教医疗委员会（BDOM），刚果民主共和国救世军和金沙萨公共卫生学院。在刚果民主共和国，我们的研究结果将为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计划可以很容易地整合到整个低收入和中等收入国家的其他预防母婴传播计划。

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.