Challenges and outcomes of implementing a national syphilis follow-up system for the elimination of congenital syphilis in Cambodia: a mixed-methods study.

OBJECTIVES: We aimed to describe the challenges and outcomes of implementing a national syphilis follow-up system to improve syphilis management in maternal and child health (MCH) services in Cambodia. DESIGN: Operational study; quantitative cohort data and cross sectional qualitative data. SETTING: Public health facilities at national level and in four provinces with high syphilis prevalence in Cambodia. PARTICIPANTS: Pregnant women screened for syphilis; MCH health care providers and managers. METHODS: We conducted an operational research using syphilis screening and treatment data collected from a national follow-up system (cohort data) and reported in the health management information system (HMIS) between 2019 and 2020. We also conducted indepth interviews with 16 pregnant women and focus group discussions with 37 healthcare providers and managers. Descriptive statistics and thematic content analysis were used. OUTCOME MEASURES: Syphilis testing and treatment results and perceptions regarding these services. RESULTS: A total of 470 pregnant women who tested positive in rapid syphilis testing were recorded in the national syphilis follow-up system in 2019-2020. Of these, 71% (332 of 470) received a rapid plasma reagin (RPR) test and 95% (n=315) tested positive; 78% (246 of 315) received any syphilis treatment and only 28% (88 of 315) were treated adequately with benzathine penicillin G (BPG). Data from four provinces with high syphilis prevalence (more closely monitored) showed higher testing and treatment rates than at the national level. HMIS aggregated data reported a higher number of pregnant women screened and treated for syphilis than the follow-up system during the same period. Barriers to syphilis testing and treatment included late antenatal care, long distance to RPR testing and treatment, partners' lack of support to reach the health facility, BPG stockout and poor adherence to oral treatment in the absence of BPG. Providers and managers reported a lack of communication across services, insufficient skills to treat infants and absence of clear guidance regarding the revised follow-up system. Study findings contributed to changes in operating procedures nationwide to facilitate access to syphilis testing and adequate treatment and a systematic follow-up of pregnant women and exposed infants. CONCLUSIONS: Study results contributed to informing improvements to syphilis management in MCH services in Cambodia.

Access to prevention of mother-to-child transmission of HIV along HIV services cascade through integrated active case management in 15 operational districts in Cambodia.

INTRODUCTION: Following the introduction of option B+ in 2013, and with the perspective of eliminating mother-to-child transmission of HIV by 2025, Cambodia has implemented an integrated active case management (IACM) approach since 2014 to improve the notification and follow-up of all HIV-infected cases including pregnant women, and to ensure access to and use of the full prevention of mother-to-child transmission (PMTCT) service package by HIV-infected pregnant women and their HIV-exposed infants. This study aimed to analyse PMTCT cascade data in 15 operational districts (ODs) implementing the IACM approach in Cambodia. METHODS: We analysed PMTCT cohort data from 15 ODs implementing IACM approach between 1 January 2014 and 31 December 2016. We measured key indicators along the PMTCT cascade and compared them to available (cross-sectional) PMTCT indicators during the 2011 to 2013 period. RESULTS: During the period 2014 to 2016, among 938 identified HIV-infected pregnant women, 308 (32.8%) were tested HIV positive during their pregnancy, 9 (1.0%) during labour, while the remaining 621 (66.2%) were women on antiretroviral therapy (ART) who became pregnant. During the study period, 867 (92.4%) of the 938 women received ART during pregnancy and labour. Subsequently, 456 (85.6%) of the 533 HEI born and alive during the study period received 6-week antiretroviral (ARV) prophylaxis, 390 (76.6%) and 396 (77.8%) of the 509 infants aged six weeks or older received cotrimoxazole prophylaxis and HIV-DNA PCR test respectively. Among the 396 HEI who received HIV-DNA PCR test, 7 (1.8%) were found HIV positive. The comparison with cross-sectional PMTCT indicator obtained during the previous 2011 to 2013 period in the same 15 ODs, showed a significant increase in ARV uptake among HIV-infected pregnant women (from 72.3% to 92.4%), in cotrimoxazole uptake (from 41.6% to 73.2%), and in HIV-DNA PCR testing coverage among HEI (from 41.2% to 74.3%). CONCLUSIONS: The implementation of option B+ and IACM may have contributed to the improvement of the PMTCT cascade in Cambodia. However, some gaps in accessing PMTCT services along the HIV cascade persist and need to be addressed.