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What interventions are effective in improving uptake and retention of HIV-positive pregnant and breastfeeding women and their infants in prevention of mother to child transmission care programmes in low-income and middle-income countries? A systematic review and meta-analysis
  1. Lisa M Puchalski Ritchie1,2,3,
  2. Monique van Lettow4,5,
  3. Ba Pham6,
  4. Sharon E Straus6,7,
  5. Mina C Hosseinipour8,9,
  6. Nora E Rosenberg8,9,10,
  7. Sam Phiri8,11,12,13,
  8. Megan Landes3,4,14,
  9. Fabian Cataldo4,5
  10. on behalf of the the PURE consortium
  1. 1 Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
  2. 2 Knowledge Translation Program, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
  3. 3 Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
  4. 4 Dignitas International, Zomba, Malawi
  5. 5 University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
  6. 6 Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
  7. 7 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  8. 8 Division of Infectious Disease, University of North Carolina, Chapel Hill, North Carolina, USA
  9. 9 University of North Carolina Project, Lilongwe, Malawi
  10. 10 Department of Health Behavior, School of Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
  11. 11 Lighthouse Trust, Lilongwe, Malawi
  12. 12 Department of global health, University of washington, seattle, washington, united states
  13. 13 Department of public health, college of medicine, school of public health and family medicine, university of malawi, malawi
  14. 14 Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Lisa M Puchalski Ritchie; lisa.puchalskiritchie{at}utoronto.ca

Abstract

Objective This review was conducted to identify interventions effective in improving uptake and retention of HIV-positive mothers and their infants in prevention of mother to child transmission (PMTCT) services in low-income and middle-income countries (LMICs) in order to inform programme planning.

Methods We conducted a systematic review of studies comparing usual care with any intervention to improve uptake and retention of HIV-positive pregnant or breastfeeding women and their children from birth to 2 years of age in PMTCT services in LMICs. Twenty-two electronic databases were searched from inception to 15 January 2018, for randomised, quasi-randomised and non-randomised controlled trials, and interrupted time series studies; reference lists of included articles were searched for relevant articles. Risk of bias was assessed using the Cochrane Effective Practice and Organisation of Care group criteria. Random-effects meta-analysis was conducted for studies reporting similar interventions and outcomes.

Results We identified 29 837 articles, of which 18 studies were included in our review. Because of heterogeneity in interventions and outcome measures, only one meta-analysis of two studies and one outcome was conducted; we found a statistically significant increase in antiretroviral therapy (ART) use during pregnancy for integration of HIV and antenatal care relative to standard non-integrated care (pooled AOR=2.69; 95% CI 1.25 to 5.78, p=0.0113). The remaining studies assessing other patient, provider or health system interventions were synthesised narratively, with small effects seen across intervention categories for both maternal and infant PMTCT outcomes based predominately on evidence with moderate to high risk of bias.

Conclusions Evidence on the effectiveness of interventions to improve uptake and retention of mothers and infants in PMTCT care is lacking. Our findings suggest that integration of HIV and antenatal care may improve ART use during pregnancy. Future studies to replicate promising approaches are needed. Improved reporting of key methodological criteria will facilitate interpretation of findings and improve the utility of evidence to PMTCT programme planners.

PROSPERO registration number CRD42015020829.

  • HIV
  • prevention of mother to child transmission
  • interventions
  • uptake
  • retention

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Footnotes

  • Contributors LMPR and MvL conceived the study. LMPR and SES developed the search strategy. LMPR prepared and registered the protocol. LMPR and MvL completed all stages of article screening, data abstraction and risk of bias appraisal. LMPR prepared the initial evidence tables and manuscript. LMPR conducted the meta-analysis with support from BP. MCH, NER, SP, ML and FC provided content expertise and assisted with preparation of the protocol and manuscript. All authors provided critical revision of the manuscript.

  • Funding LMPR was funded by a KT Canada Strategic Training Initiative in Health Research Fellowship award in 2014. SES is funded by a Tier 1 Canada Research Chair in Knowledge Translation and Quality of Care. NER was funded by the National Institute of Mental Health (Grant K99 MH104154-01A1) and the National Institute of Allergy and Infectious Diseases (P30 AI50410 and R01 AI131060-01).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data available.

  • Patient consent for publication Not required.

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