Integration of Neonatal and Child Health Interventions with Pediatric HIV Interventions in Global Health

3.2.1. Health outcomes of children

Nine articles assessed the health outcomes of children in the mother-child dyad when services were integrated. These articles described interventions within four main clinical platforms: nutrition services, pediatric inpatient wards, child survival programs and TB clinics (Table 6).

Four articles assessed the integration of HIV care and nutrition services, and found varied effects on child health outcomes. Two articles reported positive health outcomes when HIV services were integrated into nutrition services: Amadi et al.23 found a reduction in the child mortality rate due to acute malnutrition when a comprehensive community childhood malnutrition program incorporated HIV testing services. Over the three-year program, the authors noted a 0.5% mortality rate with moderate acute malnutrition (MAM) and a 4.2% mortality rate with severe acute malnutrition (SAM), which compared to concomitantly reported inpatient SAM mortality rates ranging from 3-35%.24 In another study, Kim et al. reported on the integration of HIV care and treatment, including HIV testing, ART, and opportunistic infection management, into an outpatient therapeutic feeding program.25 The authors found that prompt ART initiation within 21 days of diagnosis was associated with increased likelihood of nutritional recovery (OR: 5.4, 95% CI: 2.0 - 14.5). The two other studies assessed the integration of nutrition supplement services into HIV PMTCT programs and found variable effects on infant health outcomes.20,21 In a cohort of 2387 infants whose mothers had receive ART during pregnancy, Duggan et al. found that infants receiving micronutrient supplementation (n=1193) demonstrated a significant reduction in morbidities, including fewer hospitalizations (P = 0.035), episodes of fever (P = 0.005), and episodes of fever and cough (P =0.019) compared to a control group who did not receive micronutrient supplementation.20 In another study, Kindra et al. found no difference in weight gain between infants whose HIV-positive breastfeeding mothers had received a nutritional supplement paste and a control group.21 Reasons given for no difference between the groups was non-adherence due to stigma that mothers perceived being seen carrying the supplement package and the sweet taste of the supplement.

One study detailed health outcomes for children when HIV testing was integrated into pediatric inpatient wards. Preidis et al. found that routine hospital-based provider initiated testing and counseling (PITC) identified younger patients (median 25.0 vs 53.5 months) with more severe disease (22.2% vs 7.8% in clinical stage IV)9 compared with community-based testing. 26 In addition, more children identified in the hospital were eligible for ART based on age (47% vs 23% in community), and were on ART 12 months after diagnosis (91.4% vs 75.0%, p = 0.005). The mortality rate for hospital-identified children (15.5%) was double the mortality rate for community-identified children (7.8%) (p<0.0125).

Three articles found improvement in child outcomes when child survival programs and HIV PMTCT services were integrated. The first article described a comprehensive community-based home visit approach to maternal and newborn care for HIV-positive women and their infants.27 Women in the intervention arm received seven community health worker (CHW) home visits peri-partum to provide care consistent with ICMI, PMTCT, lactation counseling and newborn care guidelines, while control participants received three social welfare counseling visits without a health component. Prevalence of exclusive breastfeeding at 12 weeks increased among women receiving the intervention (29%) compared with control (15%) (RR 1.92), and there was a trend towards more infants in the intervention arm receiving a DNA-PCR test (73.6% vs 66.6%). No difference was seen between study arms in HIV-free infant survival.

Lilian et al. assessed the effect of an intervention providing early HIV testing (<6 weeks of age) in a postnatal care setting and found a modest effect on infant mortality, demonstrating a 16% mortality rate in the study population as compared to the national mortality rate of 20%.28 The third study described an integrated, comprehensive child survival program that incorporated HIV PMTCT care, demonstrating high rates of infant survival and retention in care.29 This intervention included access to home-based care, PMTCT services, clean water, nutrition support and socioeconomic support, and found that the probability of 18-month survival of HEI was 93% (95% CI: 0.91 to 0.94) and the infant retention rate in the same time period was 88% (95% CI: 0.86 to 0.90).

Patel et al. found a positive effect on child health outcomes from integration of HIV treatment services into a nurse-centered pediatric TB clinic, demonstrating greater weight gain among HIV-positive children receiving TB treatment who initiated ART compared to those who did not (2.2 vs. 0.7 kg/m², P = 0.08). 30

3.2.2. Service uptake

Eighteen articles assessed the effect of integrated child health and HIV platforms on the uptake of those services by beneficiaries. Most of the articles used caregiver consent to services as a proxy for child consent. Services included HIV testing and immunization services, post-natal childhood survival services, provider initiated counseling and testing (PITC) in inpatient and outpatient wards, and nutrition programming (Table 7).

Five articles examined how integration affects the uptake of HIV testing and immunization services.31-36 To assess the effect of integration on HIV testing uptake, McCollum et al. compared the rate of consent by caregivers to infant HIV DNA-PCR testing at EPI clinics compared with at under-fives clinics, and found a 7-fold greater proportion of infants received the test at EPI clinics (84.2% vs 11.4%, p<0.001) than those being seen at the under-fives clinic.31 Not only was the proportion of children tested at the EPI clinic greater, but those children who received HIV DNA-PCR testing at this location were also 2.5 months younger (3.1 vs 5.6, p<0.001), and were about three times more likely to return for their DNA-PCR results and enroll in HEI care than those tested at the under-fives clinic (78.6% vs 25.0%, p<0.001). When opt-out HIV testing was integrated into EPI clinics, Wang et al. found that, compared to the control arm, the numbers of infants receiving testing in the intervention arm increased on average by 16.6% monthly (90% CI: -7%, 46%, p = 0.26) and increased in the “comprehensive” intervention arm on average by 10% monthly (90% CI: -10%, 36%, p = 0.43).31 Ong’ech et al. found that infants in their integrated “MCH model” were over 2 times more likely to receive testing for HIV antibodies at 1 year of age, than in the control (ART clinic) model (95% CI: 1.57-3.18).34 Patel et al. studied the effect of a community based play-center model on the uptake of HIV testing of children and found that just 59% (410/697) of the enrolled children were tested, but all 74 children found HIV positive were successfully initiated on ART.36

Levin et al. observed a lower uptake of testing for infants among mothers of unknown or undisclosed status (8/24; 33.3%) compared with a 77% uptake of infant testing among known HIV-positive mothers (83/107; 77.6%), when offering HIV testing for infants at their 18 month immunization appointment.35 Rollins et al. found that when HIV testing was offered at the EPI clinic, 90% of mothers attending agreed to HIV testing of their infants, yet only 57% returned for results.37

When assessing the effect of integration of HIV services on immunization uptake, Wang et al. found that integrating HIV testing services with infants immunization services at under-five clinics did not have a significant effect on DPT1 immunization uptake, yielding an average of 0.86 more doses of DPT1 per month compared to facilities that did not receive the intervention.33 Goodson et al., however, found variations between vaccines administered in rural and urban sites after early infant diagnostic (EID) HIV testing was integrated. At the urban sites, doses for later age vaccines increased (pentavalent, polio and measles up 12%, 8% and 11%) while in rural sites, vaccine doses given by the first month decreased by 33% and 35%, and vaccine doses given later in life decreased by 23%, 28%, and 28% respectively, compared to baseline at rural clinics.32 Ong’ech et al. found that infants in the integrated “MCH model” arm were 1.14 times (95% CI: 1.04 to 1.26) more likely to attend the 14-week immunization visit.34 Patel also found that 90% of children enrolled in the community based play-center model were fully immunized (n=629), compared with the national coverage estimates of 75%.36 Levin and McCollum (2012) did not include an assessment of the effect of integration on immunization service uptake.

Six articles found that postnatal follow-up with integrated HIV and childhood survival interventions increased service uptake.27,29,38-41 Mazia et al. observed that integrating PMTCT services into postnatal care led to a 20-fold increase in the number of mothers returning for a post-natal visit within 3 days of the birth; breastfeeding by HIV-positive mothers increased by 41%; and provision of cotrimoxazole prophylaxis for HIV-exposed infants increased by 24%.42 Similarly, Tomlinson et al. found that mothers who received more frequent CHW home visits demonstrated double the rate of exclusive breastfeeding (RR1.92; 95% CI: 1.59–2.33); an increase in the number of infants with an HIV test by six weeks of age (67% vs. 74%, RR1.10); and higher cotrimoxazole uptake at 12 weeks postpartum (37% vs. 43%, RR 1.17, 95% CI: 0.99–1.37).27 Gupta observed that a comprehensive package of HIV-free and child survival services led to improved uptake of contraception and treatment for diarrheal disease.29

Three articles reported on the effect of integration of antenatal care (ANC) and PMTCT services.39-41 Herlihy found that integrating ANC and PMTCT services resulted in improved six-week dried blood spot (DBS) DNA-PCR results of 55.8% from a baseline of 41.9% (P< 0.01).40 When providing ART at ANC/PMTCT sites, Turan noted that HIV care enrollment was higher in the intervention sites compared to control sites (69% versus 36% [OR=3.94, 95% CI: 1.14–13.63]), and time to HIV care enrollment was significantly shorter among women in the intervention arm (0 versus 8 days [HR =2.20, 95% CI: 1.62–3.01]).39 Finally, in decentralizing PMTCT services from HIV care and treatment sites to ANC/Labor and delivery (L&D) wards, Edmonds et al. noted that a greater absolute number of mothers were reached, however ANC/L&D wards showed poorer provision of PMTCT services (pregnancy package of services by 14 weeks 88% vs 66%; delivery of CTX and EID 97% vs 89%) than was observed in the HIV care and treatment sites.41

Four articles that explored the integration of PITC into inpatient and outpatient wards also described the positive effects of integration on the number of caregivers or children tested.43-46 Wanyenze et al. observed that 92% (n=8,990) of caregivers consented for their children to receive HIV testing in pediatric wards over a year, and the majority of these children (8663, 96.0%) had never been previously tested.43 The authors found that HIV seroprevalence among children was 12.4% on average and highest on the nutrition ward (30.8%). Substantially increased uptake of HIV testing from 40.8% to 98.5% by eligible inpatient children was also observed by Mutanga et al.44 McCollum et al. (2011) found a greater proportion of all hospitalized children received HIV testing (81.0% vs 33.3%, p < 0.001), however PITC did not improve linkage of those identified as positive to ART, although greater than 85% were ART-eligible.45 Weigel et al. found that following introduction of PITC and ART availability to inpatient pediatric wards, the median number of children per quarter accessing HIV testing (101 to 358), registration (56 to 226) and ART initiation (18 to 139) increased, although providers initiated testing in less than 10% of admitted children.46

Amadi et al. studied the integration of HIV testing into a Community Management of Acute Malnutrition program and found 97% of enrolled children were tested for HIV, with a positivity rate of 10%. In addition, 66% of identified positive children were initiated on ART.23

3.2.3. Acceptability of integrated services

Acceptability of integrated services was frequently cited in many of the articles, yet definitions of acceptability ranged from service uptake proxies to client and provider perceptions. To identify studies reporting acceptability of integrated services, we defined acceptability per Sekhon et al. as “a multi-faceted construct that reflects the extent to which people delivering or receiving a healthcare intervention consider it to be appropriate, based on anticipated or experienced cognitive and emotional responses to the intervention”.47 Using these criteria, we determined that eight articles reported on the acceptability of integrated services to patients, caregivers, or providers through interviews or focus group discussions, many of which were qualitative or semi-quantitative. The findings for these articles are summarized in Table 8.

While most articles (n=6) assessed caregiver and provider acceptability of the integration of HIV testing services (HTS) into routine child health services, two articles addressed acceptability of non-HTS services.21,38 Through interviews with HIV-positive mothers to understand non-adherence to a nutritional supplement paste provided at ANC, mothers reported the poor taste of the supplement and stigma associated with carrying a package from the clinic.21 In an intervention where providers received additional training on standard postnatal care services to improve the quality of PMTCT services, end line interviews found that mothers perceived an improvement in the quality of care and demonstrated increased knowledge and practices of post-partum and infant care.38

Of the six articles reporting on acceptability of HTS integration with child health services, five found that integrating HTS into primary healthcare settings, including routine consultation or immunization visits, was perceived as acceptable and beneficial to both caregivers and providers. Interviews with mothers revealed a range of reasons why mothers found HTS acceptable, including: supporting the child’s health; allowing for early ART initiation; informing feeding practices; protecting the mother and her family; and reducing child mortality.22,32,48 Similar results were also seen from focus group discussions in under-five clinics where mothers revealed positive attitudes to HTS and perceptions of benefits to their children’s well-being as well as their own health. In this study, no evidence was found to indicate caregivers would be less inclined to attend an under-five clinic to avoid HIV testing.33

In three articles, healthcare providers gave positive feedback during interviews on the benefits of integrated services for infants and mothers, including: increased identification of HIV-infected infants; opportunity to start infants on treatment; and saving mothers travel time and money.37,48 Staff who received extra training when PITC services were integrated into all pediatric entry points in a large hospital reported that HTS was easier to conduct for several reasons, including: the clinician could introduce the topic of HIV earlier with the client; clients were more willing to test knowing that ART was available on-site; and that provider training had reduced stigma directed towards clients for accessing HTS.44

Three articles identified caregiver or provider concerns over HIV testing as a barrier to acceptability of integrated services. At an immunization clinic, some mothers who chose not to receive testing or to allow their child to be tested on the same day of service were frightened that testing their child would reveal their own HIV status.37 Other mothers at an immunization clinic reported the misconception that HTS was required to receive immunizations, and expressed concerns over privacy and extended wait times due to integrated services.32 Despite accepting the principle of routine infant HIV testing at postnatal points of care in community health centers, Ndondoki et al. found that 61% of mothers did not return with their infant for the testing procedure.22 When interviewed, mothers gave reasons including needing partners consent; concerns of the stigma of their child testing positive, or self-stigmatization, concerns also expressed by mothers interviewed by Mutanga et al.44

3.2.4. Enablers and barriers to Service Integration

Fourteen articles discussed health system enablers and/or barriers to service integration (Table 9). Enablers that contributed to the successful integration of services centered on issues of human resource deployment and capacity, quality of services, and tools for data collection. Several articles (n=3) found that improved training of providers prior to the launch of interventions equipped them with enhanced knowledge and improved service delivery and customer service skills.37,38,46 Four articles discussed other proactive approaches to address human resources needs, including re-deployment of existing staff,44,49 hiring more staff,43 and task shifting by assigning tasks to nurses, or increasing the use of lay cadres at sites or in the community to support care coordination.30,44 One article described the success of a quality improvement approach through provider mentoring, regular supervision sessions, and spot checks of performance, as well as regular staff meetings to assess performance of PITC integration.46 Where HIV care and treatment services were integrated, one study reported that the use of low tech tools that were regularly reviewed by providers and health facility managers, such as registers, allowed regular performance review and contributed to the success of service integration.41

Barriers to successful integration identified in the articles included inadequate staffing, clinic space factors, and external health system-related barriers. Several articles reported challenges with staffing of integrated interventions, ranging from increased demand on personnel and high government mandated training fees,43,45 to insufficient staffing footprint at clinics that reduced the time providers dedicated to providing integrated services.48 Horwood et al. cited that roles and responsibilities were not well-defined between providers of integrated ANC-PMTCT services, and record keeping on what services had been received by mothers and infants was poor.50 Physical space factors were also cited, including lack of confidential testing and counseling spaces in clinics and poor patient flow.37,48 Several articles cited external health systems factors that acted as barriers to integrated services, including concerns over stock levels of HIV test kits and turnaround time for PCR results.33,44,49