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Antiretroviral therapy in antenatal care to increase treatment initiation in HIV-infected pregnant women: a stepped-wedge evaluation

Killam, William Pa,b; Tambatamba, Bushimbwa Cc; Chintu, Namwingab; Rouse, Dwighta; Stringer, Elizabetha,b; Bweupe, Maximillianc; Yu, Yonga,b; Stringer, Jeffrey SAa,b

doi: 10.1097/QAD.0b013e32833298be
Clinical Science

Background: The objective of the study was to evaluate whether providing antiretroviral therapy (ART) integrated in antenatal care (ANC) clinics resulted in a greater proportion of treatment-eligible women initiating ART during pregnancy compared with the existing approach of referral to ART.

Analysis design and methods: The evaluation used a stepped-wedge design and included all HIV-infected, ART-eligible pregnant women in eight public sector clinics in Lusaka district, Zambia. Main outcome indicators were the proportion of treatment-eligible pregnant women enrolling into HIV care within 60 days of HIV diagnosis, and of these, the proportion initiating ART during pregnancy. Adjusted odds ratios (AORs) and confidence intervals (CIs) for enrollment and initiation proportions were estimated through a logistic regression model accounting for clinical site cluster and time effects.

Results: Between 16 July 2007 and 31 July 2008, 13 917 women started antenatal care more than 60 days before the intervention rollout and constituted the control cohort; 17 619 started antenatal care after ART integrated into ANC and constituted the intervention cohort. Of the 1566 patients found eligible for ART, a greater proportion enrolled while pregnant and within the 60 days of HIV diagnosis in the intervention cohort (376/846, 44.4%) compared with the control cohort (181/716, 25.3%), AOR 2.06, 95% CI (1.27–3.34); and initiated ART while pregnant in the intervention cohort (278/846, 32.9%) compared with the control cohort (103/716, 14.4%), AOR 2.01, 95% CI (1.37–2.95).

Conclusion: An integrated ART in ANC strategy doubled the proportion of treatment-eligible women initiating ART while pregnant.

aDepartment of OB/GYN, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA

bCentre for Infectious Disease Research in Zambia

cMinistry of Health Zambia, Lusaka, Zambia.

Received 19 May, 2009

Revised 20 August, 2009

Accepted 2 September, 2009

Correspondence to William P. Killam, MD, MPH, Department of OB/GYN, University of Alabama at Birmingham School of Medicine, 1500 6th Avenue S, Room CRWH 370, Birmingham, AL 35294-0024, USA. Tel: +1 260 211 293 772; fax: +1 260 211 293 766; e-mail:

© 2010 Lippincott Williams & Wilkins, Inc.