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      Improving Retention in Care Among Pregnant Women and Mothers Living With HIV: Lessons From INSPIRE and Implications for Future WHO Guidance and Monitoring


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          Identifying women living with HIV, initiating them on lifelong antiretroviral treatment (ART), and retaining them in care are among the important challenges facing this generation of health care managers and public health researchers. Implementation research attempts to solve a wide range of implementation problems by trying to understand and work within real-world conditions to find solutions that have a measureable impact on the outcomes of interest. Implementation research is distinct from clinical research in many ways yet demands similar standards of conceptual thinking and discipline to generate robust evidence that can be, to some extent, generalized to inform policy and service delivery. In 2011, the World Health Organization (WHO), with funding from Global Affairs Canada, began support to 6 implementation research projects in Malawi, Nigeria, and Zimbabwe. All focused on evaluating approaches for improving rates of retention in care among pregnant women and mothers living with HIV and ensuring their continuation of ART. This reflected the priority given by ministries of health, program implementers, and researchers in each country to the importance of women living with HIV returning to health facilities for routine care, adherence to ART, and improved health outcomes. Five of the studies were cluster randomized controlled trials, and 1 adopted a matched cohort design. Here, we summarize some of the main findings and key lessons learned. We also consider some of the broader implications, remaining knowledge gaps, and how implementation research is integral to, and essential for, global guideline development and to inform HIV/AIDS strategies.

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          The Roles of Expert Mothers Engaged in Prevention of Mother-to-Child Transmission (PMTCT) Programs: A Commentary on the INSPIRE Studies in Malawi, Nigeria, and Zimbabwe.

          Several initiatives aiming to improve retention and adherence in Prevention of Mother-to-Child Transmission of HIV (PMTCT) programs include "expert mothers" (EMs) as a central tenet of their interventions. This article compares the role of EMs in 3 implementation research studies examining approaches for improving retention in care among mothers living with HIV.
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            Prioritizing the PMTCT implementation research agenda in 3 African countries: INtegrating and Scaling up PMTCT through Implementation REsearch (INSPIRE).

            Countries with high HIV prevalence face the challenge of achieving high coverage of antiretroviral drug regimens interventions including for the prevention of mother-to-child transmission of HIV (PMTCT). In 2011, the World Health Organization and the Department of Foreign Affairs, Trade and Development, Canada, launched a joint implementation research (IR) initiative to increase access to effective PMTCT interventions. Here, we describe the process used for prioritizing PMTCT IR questions in Malawi, Nigeria, and Zimbabwe. Policy makers, district health workers, academics, implementing partners, and persons living with HIV were invited to 2-day workshops in each country. Between 42 and 70 representatives attended each workshop. Using the Child Health Nutrition Research Initiative process, stakeholder groups systematically identified programmatic barriers and formulated IR questions that addressed these challenges. IR questions were scored by individual participants according to 6 criteria: (1) answerable by research, (2) likely to reduce pediatric HIV infections, (3) addresses main barriers to scaling-up, (4) innovation and originality, (5) improves equity among underserved populations, and (6) likely value to policy makers. Highest scoring IR questions included health system approaches for integrating and decentralization services, ways of improving retention-in-care, bridging gaps between health facilities and communities, and increasing male partner involvement. The prioritized questions reflect the diversity of health care settings, competing health challenges and local and national context. The differing perspectives of policy makers, researchers, and implementers illustrate the value of inclusive research partnerships. The participatory Child Health Nutrition Research Initiative approach effectively set national PMTCT IR priorities, promoted country ownership, and strategically allocated research resources.
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              Using Small Tests of Change to Improve PMTCT Services in Northern Nigeria: Experiences From Implementation of a Continuous Quality Improvement and Breakthrough Series Program.

              Continuous Quality Improvement (CQI) is a process where health teams systematically collect and regularly reflect on local data to inform decisions and modify local practices and so improve delivery of services. We implemented a cluster randomized trial to examine the effects of CQI interventions on Prevention of Mother-to-Child Transmission (PMTCT) services. Here, we report our experiences and challenges establishing CQI in 2 high HIV prevalence states in northern Nigeria.

                Author and article information

                J Acquir Immune Defic Syndr
                J. Acquir. Immune Defic. Syndr
                Journal of Acquired Immune Deficiency Syndromes (1999)
                JAIDS Journal of Acquired Immune Deficiency Syndromes
                1 June 2017
                15 May 2017
                : 75
                : 2
                : S111-S114
                [* ]Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland; and
                []Department of HIV/AIDS, World Health Organization, Geneva, Switzerland.
                Author notes
                Correspondence to: Nigel C. Rollins, MD, FRCPCh, Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Avenue Appia 20, CH-1211 Geneva, Switzerland (e-mail: rollinsn@ 123456who.int ).
                QAIV17904 00002
                Copyright © 2017 The Author(s). Published by Wolters Kluwer Health, Inc.

                This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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