Improving Maternal and Newborn Health Using the HIV/AIDS Program Platform in Tanz

描述（由申请人提供）：为了响应PAR-10-038，我们提议测试是否调整一个已建立的艾滋病毒/艾滋病项目支持平台来加强孕产妇和新生儿健康（MNH）服务，从而增加这些服务的吸收，从而改善艾滋病毒阴性和艾滋病毒阳性妇女及其新生儿的结果。NIAID的关键战略重点之一是利用转化研究减少健康差距和改善健康。坦桑尼亚是东非最大的国家，艾滋病毒感染率为5.7%，是世界上孕产妇和新生儿死亡率最高的国家之一。在美国总统艾滋病紧急救援计划（PEPFAR）的支持下，坦桑尼亚在提供艾滋病毒服务方面取得了显著进展，仅2009年就避免了7500名新生儿感染艾滋病毒。相比之下，为降低孕产妇和新生儿死亡率而扩大接受基本孕产妇和新生儿保健服务的努力就不那么成功了。尽管存在明确的政策和指导方针，但坦桑尼亚只有不到一半的妇女和新生儿利用高质量的妇幼保健服务。我们的初步数据表明，服务利用率低可能是由于服务质量差。服务质量差又导致健康状况不佳。为了在同样薄弱的卫生系统中取得成功，艾滋病毒规划开创了一种创新方法，升级基础设施，提供培训和质量保证，并与当地社区合作。这种最初为艾滋病毒规划制定的三管齐下的卫生系统支持战略是否可以扩大，以提高MNH服务的质量和利用率？尽管它与临床和公共卫生相关，但没有随机研究来回答这个问题。本研究将使用严谨的研究方法来确定在临床和公共卫生环境中扩展循证卫生服务的有效策略。我们建议进行一项集群随机研究，以检验以下假设：调整艾滋病毒规划战略以加强母婴健康服务（MNH+）将提高坦桑尼亚妇女基本母婴健康和艾滋病毒服务的质量和利用率。这项研究将与坦桑尼亚卫生部、伊法卡拉卫生研究所、国际艾滋病护理和治疗方案中心、避免产妇死亡和残疾方案联合进行。Pwani地区（坦桑尼亚东部）的12个保健中心将根据基线特征进行配对，并随机分配以获得支助，以提高产妇保健服务的质量和覆盖面，或加入对照组。将通过对生活在干预和控制保健中心范围内的3000名妇女进行具有人口代表性的调查，评估人口对产前、分娩、产后、预防母婴传播和艾滋病毒护理的利用情况。将使用详细的设施数据、ICAP的监测框架和结构化的临床观察来跟踪干预措施的质量和实施程度的改进。了解艾滋病毒经验是否可以用于孕产妇和新生儿卫生保健，有助于将证据从床边转化为社区（T2转化），以挽救低收入国家孕产妇和新生儿的生命。

DESCRIPTION (provided by applicant): In response to PAR-10-038, we propose to test whether adapting an established HIV/AIDS program support platform to strengthen maternal and newborn health (MNH) services will increase uptake of these services and thus improve outcomes for both HIV-negative and HIV-positive women and their newborns. One of NIAID's key strategic priorities is to reduce health disparities and improve health by using translational research. Tanzania, the largest country in East Africa, has an HIV prevalence of 5.7% and some of the highest maternal and neonatal mortality rates in the world. With the support of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), Tanzania has made remarkable progress in providing HIV services, averting 7,500 newborn HIV infections in 2009 alone. In contrast, expanding uptake of basic maternal and newborn health (MNH) services needed to reduce maternal and newborn mortality has been less successful. Fewer than half of Tanzania's women and newborns utilize high-quality MNH services, despite the existence of well-defined policies and guidelines. Our preliminary data suggest that low service utilization may be due to poor quality of services. Poor quality of services in turn results in poor health outcomes. To succeed in the same weak health systems, HIV programs have pioneered an innovative approach to upgrade infrastructure, provide training and quality assurance, and work with local communities. Could this three-pronged health system support strategy originally developed for HIV programs be expanded to improve the quality and uptake of MNH services? Despite its clinical and public health relevance, there are no randomized studies to answer this question. This study will use rigorous research methods to define effective strategies for scaling evidence- based health services in clinical and public health settings. We propose to undertake a cluster-randomized study to test the hypothesis that adapting HIV program strategies to strengthen MNH services (MNH+) will increase quality and utilization of essential MNH and HIV services among Tanzanian women. The study will be done jointly with the Tanzania Ministry of Health, Ifakara Health Institute, the International Center for AIDS Care and Treatment Programs (ICAP), the Averting Maternal Death and Disability Program. Twelve health centers in Pwani Region (eastern Tanzania) will be paired on baseline characteristics and randomly allocated to receive support to improve the quality and reach of MNH services or join the control group. Population-level utilization of antenatal, delivery, postnatal, PMTCT and HIV care will be assessed using population- representative surveys of 3000 women living within the catchments of intervention and control health centers. Improvements in quality and extent of implementation of the intervention will be tracked using detailed facility data, using ICAP's monitoring frameworks, and structured clinical observation. Understanding whether the HIV experience can be leveraged for maternal and newborn health care can assist in the translation of evidence from bedside to the community (T2 translation) to save maternal and newborn lives in low-income countries. PUBLIC HEALTH RELEVANCE: There are massive global disparities in maternal, newborn, and HIV/AIDS mortality, with sub-Saharan Africa most severely affected. In the past eight years the President's Emergency Plan for AIDS Relief (PEPFAR), an HIV prevention and treatment program, has successfully overcome structural health system barriers in low- income countries to provide HIV testing, care, and treatment for millions of people. This cluster-randomized implementation research study will test whether adapting and expanding PEPFAR's health system support strategy to strengthen maternal and newborn health services can improve the utilization, equity, and quality of maternal and newborn health services and HIV services in eastern Tanzania-an area with high HIV prevalence and high rates of maternal and newborn mortality.