A learning agenda to build the evidence base for strengthening global health information systems.

BACKGROUND: Evidence-based interventions are necessary for planning and investing in health information systems (HIS) and for strengthening those systems to collect, manage, sort and analyse health data to support informed decision-making. However, evidence and guidance on HIS strengthening in low- and middle-income countries have been historically lacking. OBJECTIVE: This article describes the approach, methods, lessons learned and recommendations from 5 years of applying our learning agenda to strengthen the evidence base for effective HIS interventions. METHODS: The first step was to define key questions about characteristics, stages of progression, and factors and conditions of HIS performance progress. We established a team and larger advisory group to guide the implementation of activities to build the evidence base to answer questions. We strengthened learning networks to share information. RESULTS: The process of applying the learning agenda provided a unique opportunity to learn by doing, strategically collecting information about monitoring and evaluating HIS strengthening interventions and building a body of evidence. There are now models and tools to strengthen HIS, improved indicators and measures, country HIS profiles, documentation of interventions, a searchable database of HIS assessment tools and evidence generated through syntheses and evaluation results. CONCLUSION: The systematic application of learning agenda processes and activities resulted in increased evidence, information, guidance and tools for HIS strengthening and a resource centre, making that information accessible and available globally. IMPLICATIONS: We describe the inputs, processes and lessons learned, so that others interested in designing a successful learning agenda have access to evidence of how to do so.

Using a Quality Improvement Approach in the Prevention of Mother-to-Child HIV Transmission Program in Uganda Improves Key Outcomes and Is Sustainable in Demonstration Facilities: Partnership for HIV-Free Survival.

BACKGROUND: The Partnership for HIV-Free Survival (PHFS) in Uganda used a quality improvement (QI) approach to integrate the prevention of mother-to-child transmission (MTCT) of HIV, maternal and child health, and nutrition services, with the goal of increasing the retention of mother-baby pairs in care and decreasing vertical transmission of HIV. METHODS: This evaluation of PHFS used a retrospective longitudinal design to assess the program's association with 4 outcomes. Data were extracted from patient records from 2011 (before the program) to 2018 (after the program) at 18 demonstration, 18 scale-up, and 24 comparison facilities. Difference-in-differences analyses were conducted with significance set at P < 0.15 during and P > 0.15 or a significant continued improvement after PHFS. RESULTS: PHFS was associated with an increase in exclusive breastfeeding (EBF) (P = 0.08), 12-month retention in care (P < 0.001), and completeness of child 18-month HIV test results (P = 0.13) at demonstration facilities during program implementation. MTCT at 18 months decreased, but did not differ between groups. Increases in EBF (P = 0.67) and retention in care (P = 0.16) were sustained, and data completeness (P = 0.10) continued to increase at demonstration facilities after the program. PHFS was associated with an increase in EBF (P < 0.001) at scale-up facilities, but there was no difference between groups for retention in care, MTCT, or data completeness. Gains in EBF were lost (P = 0.08) and retention in care declined (P < 0.001) at scale-up facilities after the program. CONCLUSION: PHFS' quality improvement approach increased EBF, retention in care, and data completeness in demonstration facilities during the program and these benefits were sustained.

Decreased consumption of common weaning foods is associated with poor linear growth among HIV-exposed infants participating in the Kigali antiretroviral and breastfeeding assessment for the elimination of HIV (Kabeho) study.

OBJECTIVE: The World Health Organization recommends that complementary foods that are adequate, safe, and appropriate be introduced to infants at age 6 months. Using an innovative modeling technique, we examine patterns of nutrient intake in HIV-exposed and uninfected (HEU) infants and establish their relationship with growth. METHODS: Single-day dietary recalls and anthropometrics were collected every two to 3 months from 543 infants living in Kigali, Rwanda, and attending clinics for the prevention of mother-to-child HIV transmission. A common weaning food index (CWFI) was calculated in grams and nutrient density for infants to reflect the extent to which the infants consumed the weaning foods typical of this population at ages 6 to 10, 11 to 15, and 16 to 20 months. Regressions among the CWFI, length-for-age z-scores (LAZ), and weight-for-length z-scores (WLZ) were conducted to estimate the relationship between the dietary patterns and growth. RESULTS: Mean absolute intake of zinc and calcium from complementary foods was insufficient. Increasing CWFI was related to increasing cow milk consumption. The density CWFI showed a decrease in the density of iron and folate as infants consume more of the weaning foods typical of this population. Density CWFI, breastfeeding, and caloric intake act on early LAZ and WLZ and interact with one another. Among breastfed infants, those who consume little of the common weaning foods and have a high caloric intake develop deficits in LAZ and have an elevated WLZ. CONCLUSIONS: A diet that is more dominated by the typical weaning foods of this population may support a healthy growth pattern.

Determinants of growth in HIV-exposed and HIV-uninfected infants in the Kabeho Study.

HIV-exposed and HIV-uninfected (HEU) infants may be at increased risk of poor health and growth outcomes. We characterized infant growth trajectories in a cohort of HEU infants to identify factors associated with healthy growth. HIV-positive women participating in prevention of mother-to-child HIV transmission programmes in Kigali, Rwanda, were followed until their infants were 2 years old. Infant anthropometrics were regularly collected. Latent class analysis was used to categorize infant growth trajectories. Multiple logistic regression was used to estimate the odds of infants belonging to each growth trajectory class. On average, this population of HEU infants had moderate linear growth faltering, but only modest faltering in weight, resulting in mean weight-for-length z-score (WLZ) above the World Health Organization (WHO) median. Mean WLZ was 0.53, and mean length-for-age z-score (LAZ) was -1.14 over the first 2 years of life. We identified four unique WLZ trajectories and seven trajectories in LAZ. Low neonatal weight-for-age and a high rate of illness increased the likelihood that infants were in the lightest WLZ class. Shorter mothers were more likely to have infants with linear growth faltering. Female infants who were older at the end of exclusive breastfeeding were more likely to be in the second tallest LAZ class. In conclusion, the current WHO recommendations of Option B+ and extended breastfeeding may induce higher WLZ and lower LAZ early in infancy. However, there is considerable heterogeneity in growth patterns that is obscured by simply analysing average growth trends, necessitating the analysis of growth in subpopulations.

Understanding Antiretroviral Treatment Adherence Among HIV-Positive Women at Four Postpartum Time Intervals: Qualitative Results from the Kabeho Study in Rwanda.

As lifelong antiretroviral therapy (ART) for pregnant women is implemented, it is important to understand the attitudes and norms affecting women's postpartum ART adherence. This is a qualitative cross-sectional study of HIV-positive postpartum women (n = 112) enrolled in a 2-year observational prospective cohort in Rwanda. Informed by the Theory of Reasoned Action (TRA), we conducted in-depth interviews with women whose children were 0-6, 7-12, 13-18, or 21-24 months of age to describe factors contributing to adherence and changes over time. Positive ART attitudes reported by women included mothers' health promotion, prevention of infant HIV infection, higher CD4 count, and improved physical appearance. Negative attitudes were few, but included side effects and the lifelong nature of treatment. Learning from people living with HIV (PLHIV) was identified as a norm facilitating adherence; ART adherence was inhibited by fear of disclosure or stigmatization in communities and clinics. Poor adherence behaviors were common immediately after HIV diagnosis, not necessarily during prevention of mother-to-child transmission (PMTCT). Women with older children, most of whom stopped breastfeeding by 13-18 months, reported more barriers and missed doses than women with younger children. The TRA was useful in identifying the collective influence of attitudes, norms, and intentions on behavior. Findings suggest that HIV-positive women are vulnerable to poor adherence following HIV diagnosis and around the time of breastfeeding cessation. Lifelong treatment adherence can be supported through PLHIV exemplifying long-term ART use, fewer and less stigmatizing clinic visits, and counseling messages highlighting the benefits of drugs on appearance and illness prevention and incorporating biological feedback.

24-month HIV-free survival among infants born to HIV-positive women enrolled in Option B+ program in Kigali, Rwanda: The Kabeho Study.

Lifelong antiretroviral therapy (ART) provision to all pregnant HIV-positive women ("Option B+") has been recommended by the World Health Organization since 2013, but there remain limited data on the effects of Option B+ on long-term HIV-free survival in breastfeeding HIV-exposed infants. The Kigali Antiretroviral and Breastfeeding Assessment for the Elimination of HIV (Kabeho) study enrolled HIV-positive women from the third trimester of pregnancy to 2 weeks postpartum in 14 heath facilities implementing Option B+ in Kigali, Rwanda. Mother-child pairs in the longitudinal observational cohort were followed until 24 months postpartum, with HIV diagnostic testing at 6 weeks, and 9, 18 and 24 months. The Kaplan-Meier method was used to estimate HIV transmission, survival, and HIV-free survival through 24 months. We enrolled 608 HIV-positive women in 2013-2014; birth outcome data were available for 600 women and 597 live-born infants. By 6 weeks, 11 infants had died and 3 infants had confirmed HIV infection (0.5% transmission; 95% confidence interval [CI] 0.2-1.6). At 9 months, there were 9 additional deaths and 2 new infections (cumulative transmission 0.9%, 95% CI 0.4-2.2). At 18 months, there were 6 additional deaths and no new infant infections. At 24 months, there were no additional child deaths and 1 new infection (cumulative 2.2%, 95% CI 0.7-7.0), for an overall 24-month HIV-free survival of 93.2% (95% CI 89.5-95.6). Low transmission rates and high HIV-free survival at 24 months were achieved in breastfeeding infants of HIV-positive mothers receiving universal ART in urban health facilities in Rwanda, though vigilance on maintaining viral suppression for ART-experienced women is needed.

Evaluation of a male engagement intervention to transform gender norms and improve family planning and HIV service uptake in Kabale, Uganda.

Men's limited understanding of family planning (FP) and harmful cultural gender norms pose obstacles to women's FP use. Thirty-two model men called 'Emanzis' were recruited from the community in Kabale, Uganda to lead men from their peer group through a 10-session curriculum designed to transform gender norms and motivate men to engage in FP and HIV services. Cross-sectional surveys were conducted before (n = 1251) and after (n = 1122) implementation. The Gender Equitable Men (GEM) Scale was used to assess the effect on gender attitudes. The intervention achieved negligible changes in responses to GEM items. Improvements in some gender-influenced health-seeking behaviours and practices in men were noted, specifically in visiting health facilities, HIV testing, and condom use. For future application, the intervention should be adapted to require higher peer educator qualifications, longer intervention duration, and more frequent supervision. Practical guidance is needed on where to direct investments in gender-transformative approaches for maximum impact.

Detectable Viral Load in Late Pregnancy among Women in the Rwanda Option B+ PMTCT Program: Enrollment Results from the Kabeho Study.

There are limited viral load (VL) data available from programs implementing "Option B+," lifelong antiretroviral treatment (ART) to all HIV-positive pregnant and postpartum women, in resource-limited settings. Extent of viral suppression from a prevention of mother-to-child transmission of HIV program in Rwanda was assessed among women enrolled in the Kigali Antiretroviral and Breastfeeding Assessment for the Elimination of HIV (Kabeho) Study. ARV drug resistance testing was conducted on women with VL>2000 copies/ml. In April 2013-January 2014, 608 pregnant or early postpartum HIV-positive women were enrolled in 14 facilities. Factors associated with detectable enrollment VL (>20 copies/ml) were examined using generalized estimating equations. The most common antiretroviral regimen (56.7%, 344/607) was tenofovir/lamivudine/efavirenz. Median ART duration was 13.5 months (IQR 3.0-48.8); 76.1% of women were on ART at first antenatal visit. Half of women (315/603) had undetectable RNA-PCR VL and 84.6% (510) had <1,000 copies/ml. Detectable VL increased among those on ART > 36 months compared to those on ART 4-36 months (72/191, 37.7% versus 56/187, 29.9%), though the difference was not significant. The odds of having detectable enrollment VL decreased significantly as duration on ART at enrollment increased (AOR = 0.99, 95% CI: 0.9857, 0.9998, p = 0.043). There was a higher likelihood of detectable VL for women with lower gravidity (AOR = 0.90, 95% CI: 0.84, 0.97, p = 0.0039), no education (AOR = 2.25, (95% CI: 1.37, 3.70, p = 0.0004), nondisclosure to partner (AOR = 1.97, 95% CI: 1.21, 3.21, p = 0.0063) and side effects (AOR = 2.63, 95% CI: 1.72, 4.03, p<0.0001). ARV drug resistance mutations were detected in all of the eleven women on ART > 36 months with genotyping available. Most women were receiving ART at first antenatal visit, with relatively high viral suppression rates. Shorter ART duration was associated with higher VL, with a concerning increasing trend for higher viremia and drug resistance among women on ART for >3 years.

HIV-positive pregnant and postpartum women's perspectives about Option B+ in Malawi: a qualitative study.

INTRODUCTION: The implementation of lifelong antiretroviral treatment (ART) for all pregnant women (Option B+) in Malawi has resulted in a significant increase in the number of HIV-positive pregnant women initiating treatment. However, research has highlighted the challenge of retaining newly initiated women in care. This study explores barriers and facilitators that affect a woman's decision to initiate and to adhere to Option B+. METHODS: A total of 39 in-depth interviews and 16 focus group discussions were conducted. Eligible women were ≥18 years old, living with HIV and either pregnant and receiving antenatal care from a study site or had delivered a child within the last 18 months, breastfed their child and received services at one of the study sites. Eligible women were identified by healthcare workers (HCWs) in the antenatal clinic and ART unit. Focus groups were also conducted with HCWs employed in these departments. Qualitative data were analyzed using Maxqda version 10 (VERBI Software, Berlin, Germany). RESULTS: The general perception towards the drug regimen used in Option B+ was positive; women reported fewer side effects and acknowledged the positive benefits of ART. Women felt hopeful about prolonging their life and having an HIV-uninfected baby, yet grappled with the fact that ART is a lifelong commitment. Women and HCWs discussed challenges with the counselling services for prevention of mother-to-child HIV transmission under the new Option B+ guidelines, and many women struggled with initiating ART on the same day as learning their HIV status. Women wanted to discuss their circumstances with their husbands first, receive a CD4 count and obtain an HIV test at another facility to confirm their HIV status. HCWs expressed concern that women might just agree to take the drugs to please them. HCWs also discussed concerns around loss to follow-up and drug resistance. CONCLUSIONS: Although Option B+ has significantly increased the number of women initiating ART, there are still challenges that need to be addressed to strengthen initiation, adherence and retention in care. Strategies to strengthen the counselling services upon diagnosis need to be developed to improve same-day initiation of ART and long-term adherence.

Barriers; Facilitators and Recommendations for the Early Infant Diagnosis and Treatment (EIDT) Cascade: A Qualitative Study in Malawi

Background. Identifying and testing all HIV-exposed infants (HEIs) by 2 months of age with rapid antiretroviral therapy (ART) initiation for those infected is critical to survival. Yet in 2009 only 29% of HEIs in need of ART received treatment in Malawi.Objectives. To understand barriers; facilitators and recommendations for five key steps in the early infant diagnosis and treatment (EIDT) cascade: (1) identification of HEIs; (2) infant testing; (3) sample processing and transport; (4) reporting results to mothers; (5) ART initiation for HEI.Methods. Semistructured interviews were conducted through convenience sampling with mothers of infants eligible for EIDT (n=47) and with healthcare workers (HCWs) providing EIDT (n=20) in five facilities; in April 2013. Results. (1) Reliance on the health passport to identify HEIs is both barrier; as women may not attend appointments with their passports; and facilitator; for documentation of HIV-exposure status. Use of trained health surveillance assistants in EIDT enhances cascade steps 1 and 2; but requires increased supervision. (2) Women struggle to accept their own HIV status; yet test results for an HEI is a motivator. Sensitisation through local leadership facilitates EIDT. (3) A reliable transport system is needed. (4) Maintaining appointments to report results to women motivates them. (5) Mothers were reluctant to give ART to young; apparently healthy infants. Conclusion. Both women and healthcare workers are motivated by test results for HEIs. The inclusion of community education can improve all steps in the EIDT cascade; including information that HEIs need ART

Access to HIV prevention and care for HIV-exposed and HIV-infected children: a qualitative study in rural and urban Mozambique.

BACKGROUND: Follow-up of HIV-exposed children for the delivery of prevention of mother-to-child transmission services and for early diagnosis and treatment of HIV infection is critical to their survival. Despite efforts, uptake of postnatal care for these children remains low in many sub-Saharan African countries. METHODS: A qualitative study was conducted in three provinces in Mozambique to identify motivators and barriers to improve uptake of and retention in HIV prevention, care and treatment services for HIV-exposed and HIV-infected children. Participant recommendations were also gathered. Individual interviews (n = 79) and focus group discussions (n = 32) were conducted with parents/caregivers, grandmothers, community leaders and health care workers. Using a socioecological framework, the main themes identified were organized into multiple spheres of influence, specifically at the individual, interpersonal, institutional, community and policy levels. RESULTS: Study participants reported factors such as seeking care outside of the conventional health system and disbelief in test results as barriers to use of HIV services. Other key barriers included fear of disclosure at the interpersonal level and poor patient flow and long waiting time at the institutional level. Key facilitators for accessing care included having hope for children's future, symptomatic illness in children, and the belief that health facilities were the appropriate places to get care. CONCLUSIONS: The results suggest that individual-level factors are critical drivers that influence the health-seeking behavior of caregivers of HIV-exposed and HIV-infected children in Mozambique. Noted strategies are to provide more information and awareness on the benefits of early pediatric testing and treatment with positive messages that incorporate success stories, to reach more pregnant women and mother-child pairs postpartum, and to provide counseling during tracing visits. Increasing uptake and retention may be achieved by improving patient flow at the institutional level at health facilities, by addressing concerns with family decision makers, and by working with community leaders to support the uptake of services for HIV-exposed children for essential preventive care.

How the global call for elimination of pediatric HIV can support HIV-positive women to achieve their pregnancy intentions.

The global call to eliminate new pediatric HIV infections requires a comprehensive approach, including consideration of the pregnancy intentions of HIV-positive women. This paper presents a literature review on the interface between pediatric HIV elimination and the pregnancy intentions of HIV-positive women, focusing on the four prongs of prevention of mother-to-child transmission: primary prevention of HIV infection in women; preventing unintended pregnancies in HIV-positive women; preventing transmission of HIV from infected women to their infants; and providing care, support and treatment to HIV-positive women, their children and their families. The paper describes the role of pregnancy intentions in determining appropriate health services for HIV-positive women - including family planning, reproductive and obstetric care, and HIV-related services - and explains how these essential health services are linked to improving maternal health, reducing child mortality and eliminating pediatric HIV. The paper provides context for the recent UNAIDS-led call to eliminate pediatric HIV, which will require a complete, integrated approach to providing family planning, maternal and child health, and HIV-related services for all HIV-affected individuals and families. Ensuring that HIV-positive women have access to high-quality health services to enable them to choose whether and when to have children is an essential component of this approach.

Towards the Elimination of Pediatric HIV: Enhancing Maternal, Sexual, and Reproductive Health Services.

Almost 10 years ago, the United Nations adopted a comprehensive, four-pronged approach for the prevention of mother-to-child transmission of HIV (PMTCT). Despite all four prongs being central to the elimination of pediatric HIV, and the health of the mother being critical to reaching this goal, PMTCT programs have historically focused more attention on preventing HIV transmission from mother to child (prong 3) than on preventing HIV in women of reproductive age (prong 1) and preventing unintended pregnancies in women living with HIV (prong 2). In this commentary, experts from the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) argue that within the context of efforts to eliminate pediatric HIV, there are many ways to keep women living with HIV alive and at the center of the response to the global epidemic. One of the ways to do this is to enhance maternal and sexual and reproductive health (SRH) services. Within the elimination agenda, integration and linkages between PMTCT and comprehensive SRH services can keep mothers alive and at the center of the response. The commentary highlights some of the foundation's global health work supporting, evaluating and enhancing maternal and SRH services provided to women living with HIV and proposes concrete actions for donors, researchers, policy makers and program implementers to further enhance maternal and SRH services within the context of PMTCT. If keeping women living with HIV is an integral component of the elimination of pediatric HIV agenda, maternal and SRH research, policies and programs need to be strengthened within the context of PMTCT. Donor funding and priorities for PMTCT also need to be more supportive of primary prevention of HIV infection among women of childbearing age and preventing unintended pregnancies among women living with HIV.

A comparison of the National Center for Health Statistics and new World Health Organization growth references for school-age children and adolescents with the use of data from 11 low-income countries.

BACKGROUND: In 2007 new World Health Organization (WHO) growth references for children aged 5-19 y were introduced to replace the National Center for Health Statistics (NCHS) references. OBJECTIVE: This study aimed to compare the prevalence of stunting, wasting, and thinness estimated by the NCHS and WHO growth references. DESIGN: NCHS and WHO height-for-age z scores were calculated with the use of cross-sectional data from 20,605 schoolchildren aged 5-17 y in 11 low-income countries. The differences in the percentage of stunted children were estimated for each year of age and sex. The z scores of body mass index-for-age and weight-for-height were calculated with the use of the WHO and NCHS references, respectively, to compare differences in the prevalence of thinness and wasting. RESULTS: No systematic differences in mean z scores of height-for-age were observed between the WHO and NCHS growth references. However, z scores of height-for-age varied by sex and age, particularly during early adolescence. In children for whom weight-for-height could be calculated, the estimated prevalence of thinness (WHO reference) was consistently higher than the prevalence of wasting (NCHS reference) by as much as 9% in girls and 18% in boys. CONCLUSIONS: In undernourished populations, the application of the WHO (2007) references may result in differences in the prevalence of stunting for each sex compared with results shown when the NCHS references are used as well as a higher estimated prevalence of thinness than of wasting. An awareness of these differences is important for comparative studies or the evaluation of programs. For school-age children and adolescents across all ranges of anthropometric status, the same growth references should be applied when such studies are undertaken.

Providing support to IPV victims in the emergency department: vignette-based interviews with IPV survivors and emergency department nurses.

The authors compare perspectives of intimate partner violence (IPV) survivors and emergency department (ED) nurses on types of social support IPV victims need at different stages of readiness to disclose and leave a relationship. Qualitative interviews (16 IPV survivors, 10 ED nurses) center on women's responses to vignettes that illustrate different stages of readiness. Survivors mention fear as a barrier for action, whereas nurses are more likely to say that the woman is in denial. Survivors emphasize emotional support and respect, whereas nurses emphasize informational and instrumental support. IPV victims desire appropriate, respectful responses by nurses, suitable to their stage of readiness. Nurses need more insight into women's decisions to disclose and leave a relationship and skills to provide emotional support.