Secondary Logo

Journal Logo

Integrating PMTCT Into Maternal, Newborn, and Child Health and Related Services

Experiences From the Global Plan Priority Countries

Kiragu, Karusa, PhD, MPH; Collins, Lynn, MD, PhD, MPH; Von Zinkernagel, Deborah, BSN, MS, SM; Mushavi, Angela, MBChB, MMed

JAIDS Journal of Acquired Immune Deficiency Syndromes: May 1st, 2017 - Volume 75 - Issue - p S36–S42
doi: 10.1097/QAI.0000000000001323
Supplement Article
Free

Abstract: The urgency to scale-up sustainable programs for the prevention of mother-to-child transmission of HIV (PMTCT) prompted priority countries of the Global Plan Toward the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (Global Plan) to expand the delivery of PMTCT services through greater integration with sexual and reproductive health and child health services. Countries approached integration—what, where, and how services are provided—in diverse ways, with predominantly favorable results. Approaches to integrated services have increased access to a broader range of PMTCT interventions, and they also have proved to be largely acceptable to clients and providers. The integration of PMTCT interventions with maternal, newborn, and child health settings was supported by strategies to reconfigure service delivery to provide additional services, including shifting tasks to nurses (such as initiating antiretroviral therapy and providing long-term follow-up). This was complemented by supporting community outreach and integrating HIV and sexual and reproductive health services bidirectionally, including by providing family planning through antiretroviral therapy clinics and HIV testing in family planning clinics. A systematic and rigorous study of country experiences integrating HIV and maternal, newborn, and child health services, including maternal and pediatric TB services, cost analysis, could provide valuable lessons and demonstrate how such integration can improve systems for health care delivery.

*UNAIDS, Joint United Nations Program on HIV and AIDS, the Office of Global Fund and Global Plan Affairs, UNAIDS, Geneva, Switzerland;

Population and Family Health, Columbia University Medical Center, New York, NY;

United Nations Population Fund, New York, NY; and

§AIDS and TB Unit, Ministry of Health and Child Welfare, Harare, Zimbabwe.

Correspondence to: Karusa Kiragu, PhD, MPH, UNAIDS, 20 Avenue Appia, 1211 Geneva 27, Switzerland (e-mail: kiraguk@unaids.org).

The authors have no funding or conflicts of interest to disclose.

K.K. and L.C. contributed equally to the article.

Back to Top | Article Outline

INTRODUCTION

This article describes select country approaches to integrating services for the prevention of mother-to-child transmission of HIV (PMTCT) and identifies some key programming considerations. It focuses on the priority countries of the Global Plan Toward the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (Global Plan). There were 22 Global Plan focus countries: Angola, Botswana, Burundi, Cameroon, Chad, Côte d'Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana, India, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, South Africa, Uganda, United Republic of Tanzania, Swaziland, Zambia, and Zimbabwe. However data for India were unavailable, and so focus was on 21 countries.1 This paper describes how selected aspects of integration were implemented across the countries, what key outcomes were achieved, and what lessons were learned. However, it does not seek to compare and critique how countries implemented integration or evaluate attribution of outcomes to integration in a robust manner.

There is currently no standardized definition of integration, established framework, or country information source that captures all elements and processes of integration, making rigorous analysis and country comparison difficult. In the context of HIV and sexual and reproductive health and rights (SRHR), policy/legal approaches, health systems, and service delivery have been defined as “linkages,” of which integrated service delivery is an integral part. Although 2 indicators relevant for PMTCT integration have been developed that describe which HIV and SRHR services are combined and how they are delivered, these indicators are not yet widely used. They also are limited to HIV and do not include upstream policy and health system aspects.2–5 Definitions of integrated service delivery reflect the goal of providing clients with convenient access to the maximum number of comprehensive quality services during a single visit. Multiple models of service integration exist, ranging from services being provided by the same provider in the same room during the same visit to on-site and off-site referrals.

Back to Top | Article Outline

INTEGRATION OF SERVICES IN THE CONTEXT OF THE GLOBAL PLAN

PMTCT programs in Global Plan priority countries have become progressively integrated within maternal health (antenatal and postpartum), postnatal, pediatric, antiretroviral treatment, family planning, and tuberculosis (TB) services. Historically, PMTCT programs were sometimes described as vertical or stand-alone services,6 set apart from maternal, newborn, and child health (MNCH) when they had designated HIV health providers, separate infrastructure, dedicated funding, separate reporting, and parallel systems for planning, coordination, and management, reporting to national AIDS coordinating bodies instead of the ministries of health (where MNCH departments were located).4,7–10

From the outset, PMTCT services featured some degree of integration through inclusion of HIV information, counseling, and testing in antenatal care services. Pregnant women living with HIV were provided with infant feeding counseling and antiretroviral medicines—initially monotherapy with single-dose nevirapine or zidovudine—to prevent transmission to their infants. However, integration was incomplete. For example, the services were often provided by specialized HIV nurses or doctors in designated PMTCT rooms colocated within antenatal care or through referral to off-site antiretroviral therapy clinics. PMTCT programs became synonymous with providing services predominantly for pregnant women living with HIV, instead of serving all pregnant women or women living with HIV who were not pregnant.

With the introduction in 2000 of a comprehensive PMTCT strategy incorporating 4 prongs, however, the landscape was reset for the broader integration of PMTCT as part of other health services, particularly MNCH and family planning.11 The 4 prongs are as follows:

  • Prong 1: primary prevention of HIV infection among women of childbearing age.
  • Prong 2: preventing unintended pregnancies among women living with HIV.
  • Prong 3: preventing HIV transmission from a woman living with HIV to her infant using antiretroviral medicines.
  • Prong 4: providing appropriate treatment, care, and support to mothers living with HIV and their children and families.

Lack of adequate integration with MNCH and attention to Prongs 1 and 2 was widely acknowledged,12 and by 2007, global PMTCT guidance was unequivocal that accelerating PMTCT scale-up required delivery of all 4 prongs as part of routine quality sexual and reproductive health (SRH) and child health care; it also recommended a shift to provider-initiated HIV testing and counseling.13

The Global Plan, launched in 2011, further advanced global commitment and new targets for PMTCT, and it included the previously neglected goal of keeping mothers alive, which provided renewed emphasis on integrating PMTCT with antiretroviral therapy for women. Support for implementation of all 4 prongs was buttressed by modeling that showed achieving a 90% reduction of new HIV infections among children would not be possible without Prong 1 and 2 interventions.14

Integration of PMTCT interventions within broader health services raised many questions15:

  • Which provider would do what, when, and how?
  • What were country policies regarding the introduction of new services?
  • What training and staffing were needed, and were task shifting and task sharing needed or possible?
  • What would be the impact on workload and patient flow?
  • What supply chain adjustments would be required to ensure the availability of commodities to implement comprehensive PMTCT services?
  • Would the quality of services suffer?
  • How would the community be engaged, and how would people respond to an expanded range of available services?

Each country had to develop and implement its own strategy to achieve greater integration of services, building on global guidance, evidence, and the experiences of other countries.

Back to Top | Article Outline

MODELS OF INTEGRATED SERVICE DELIVERY

Limited research exists on the various models for integrating PMTCT services with other health services, with mixed findings about the impact on health outcomes, client uptake, health worker productivity, client waiting times, acceptability, and cost-effectiveness and cost efficiency.16–19 In the absence of a defined optimal model, Global Plan priority countries took different approaches to expanding and integrating care.20 The following examples depict illustrative country experiences with integrating PMTCT interventions into MNCH, family planning, and antiretroviral therapy services.21 Additional country experiences are reflected in Boxes 1 and 2.

Back to Top | Article Outline

“One-Stop” Integrated Service Delivery in Namibia Cited Here...

As part of an SRHR and HIV linkage project, Namibia reorganized its service delivery in clinics and health centers at 7 pilot sites in 2014 to provide integrated services through a model of “one nurse, one patient, one room.”51 Under this one-stop model, the nurse

  • follows the same client over time,
  • is trained to provide an expanded range of primary health services, and
  • facilitates referral as needed.

Analysis of baseline study at these sites conducted in 2011 and 2012, including a client time motion study, guided decision making on the optimal integration model by examining the following:

  • who (provider),
  • what (service),
  • where (setting), and
  • when (time).

The integrated model of care has done the following:

  • improved nurse productivity by 2.5 times under the one-stop model compared with the previous model of multiple providers providing separate services to clients on site during one visit;
  • reduced the average total time that clients spend waiting for services related to first antenatal care visit (down from 4 to 2 hours);
  • reduced stigma and discrimination; and
  • enabled health care providers to offer more services to clients.

Based partly on this experience, the government has developed guidance to scale-up integrated services nationwide.52 The project is entering its second phase, with a cost study and evaluation of the first phase underway.

Back to Top | Article Outline

Comprehensive Integration of HIV and SRHR in Swaziland Cited Here...

Swaziland has embarked on an ambitious plan to integrate SRHR and HIV by doing the following:

  • launching its first SRHR strategy in 2013, which fully integrates HIV services;
  • developing frameworks and protocols for its operationalization; and
  • piloting models for stigma-free integrated HIV and SRHR service delivery in 5 Centers of Excellence.27

A 2013 survey of health provider and client perceptions of integrated SRHR and HIV services revealed the following:

  • overall satisfaction with the integrated services,
  • fewer client trips required to the health clinic,
  • reduction in client expenditures on health,
  • long waiting times, and
  • staff shortages and overload.53
Back to Top | Article Outline

Integration of Adult HIV Testing With Family Planning and Postpartum Services (Prongs 1 and 3)

HIV counseling and testing serve as a gateway to treatment by diagnosing HIV status, and it can link with other prevention services, including treatment as prevention among HIV serodiscordant partners, pre-exposure prophylaxis (PrEP) and postexposure prophylaxis, and behavior change interventions.14 In Kenya, integrating HIV counseling and testing into family planning services increased uptake of services and improved overall quality of joint family planning and HIV counseling.22 In Ethiopia, testing uptake increased as much as 7-fold when the same health worker offered HIV testing and counseling and family planning services in the same room as opposed to in separate sections of the clinic.23 Over half of HIV transmission to infants currently occurs during breastfeeding,24 and countries are now offering HIV testing to mothers in the postpartum period to identify seroconversion during breastfeeding.25 In general, efforts to help pregnant women who test HIV negative in antenatal clinics to remain so have been inadequate; offering treatment to HIV seropositive partners or providing PrEP to women can protect them from acquiring HIV and transmitting it to their children.

Back to Top | Article Outline

Integration of Family Planning Into Antiretroviral Therapy, Immunization, and Community-Based Services (Prong 2)

Services for preventing unintended pregnancies among women living with HIV have been integrated into antiretroviral therapy clinics, HIV testing sites, and community-based HIV services, with some studies finding resultant increases in the uptake of family planning services and contraceptive use among women living with HIV.26 In Botswana, 9 pilot sites integrated family planning into antiretroviral therapy clinics, resulting in 79% of antiretroviral therapy clinic clients accessing family planning from 2012 to 2013.27 In Kenya, a pilot to integrate family planning services into 12 HIV care clinics enabled clients to be offered contraceptives by the same provider during the visit, which resulted in increased use of effective contraceptive methods (compared with 6 control sites where clients were referred for family planning services within the same facility). However, no difference in pregnancy rates was observed between the pilot and control sites after 1 year.28 In Ethiopia, Malawi, and Nigeria, facilities that offered family planning services at child immunization visits significantly increased contraceptive uptake, particularly among adolescents, although the study did not differentiate by HIV status.29

Back to Top | Article Outline

Integration of HIV Treatment Into Maternal Health Services (Prongs 3 and 4)

Even as late as 2009, the baseline year of the Global Plan, only 37% of pregnant women living with HIV in the 21 high-burden countries in sub-Saharan Africa were receiving antiretroviral medicines.25 Typically, only single-dose nevirapine was given to the pregnant woman, which reduced early vertical transmission by up to 50% but did not treat the illness of the women themselves. In 2010, the World Health Organization (WHO) recommended new efficacious PMTCT antiretroviral medicine regimes that required CD4 measurement for eligibility. At that time, WHO recommended 3 approaches for the use of antiretroviral medicines to prevent mother-to-child transmission of HIV: option A, option B, and option B+ (WHO,30 2010). Both option A and B approaches consisted of immediate, lifelong triple antiretroviral medicines for the most immunocompromised pregnant women (CD4 count of ≤350). For their healthier counterparts, both options consisted of a short course of antiretroviral medicines prescribed over a specified period during pregnancy and breastfeeding. After that, use would stop, resuming when the woman became pregnant again or when she met the criteria for starting treatment for her own health. Option B+ avoided that stop-and-start approach: under option B+, all pregnant or breastfeeding women diagnosed with HIV were offered treatment for life, regardless of CD4 count.30

Because Malawi did not find CD4 testing feasible on a large scale, it adopted a national policy of offering all HIV seropositive pregnant women antiretroviral therapy without a CD4 test.31,32 This new approach, described in this series by Kalua et al31 simplified antiretroviral therapy initiation and increased the number of women eligible for treatment. Consequently, Malawi established a task-shifting policy enabling nurses and midwives to initiate and manage antiretroviral therapy within maternal health services, with 426 additional antenatal care clinics able to provide antiretroviral therapy directly without referral. These actions, coupled with community follow-up, demonstrated that simplification and integration of antiretroviral therapy into MNCH services was feasible at scale and that it also provided a platform for expanded antiretroviral therapy delivery to children and other family members.

More recently, Myer et al33 in South Africa examined opportunities for integrating postnatal maternal ART services into MNCH services. This randomized trial compared outcomes for women who were retained in MNCH services and offered ART care there, versus those who were referred to general adult ART services after delivery, which is the standard of care for many countries in sub-Saharan Africa. Women in the MNCH arm of the study were retained there for 12 months or until the end of breastfeeding, after which they were transferred out to the general adult clinic. The results showed that women in the MNCH arm had higher rates of viral suppression (77% vs 56%) and longer duration of breastfeeding. They demonstrate that that integrating maternal ART into MNCH services could be a simple and highly effective strategy to support retention and adherence.

Back to Top | Article Outline

Integration of Pediatric Diagnosis and Treatment Into Postnatal and Other Settings (Prong 4)

The PMTCT continuum of care includes diagnosis for HIV-exposed children within 6 weeks after delivery, followed by immediate treatment if seropositive. By 2012, only 30% of children living with HIV in the 21 Global Plan priority countries were receiving antiretroviral therapy. In response, recommendations were put forward to expand pediatric testing and treatment access by integrating these services into pediatric wards, schools, immunization clinics, nutrition services, programs for orphans and vulnerable children, and homes through community outreach.34 In Zimbabwe, early infant diagnosis was integrated into immunization and other postnatal visits to capitalize on routine visits by mothers with their infants. Of the 139 facilities responding to a follow-up survey of 151 sites, 83% of the immunization clinics and 80% of the postnatal clinics were providing dried HIV blood spot collection and nevirapine and co-trimoxazole prophylaxis for HIV-exposed infants along with routine postnatal services. However, 73% of these facilities were offering antiretroviral therapy only through referral.35

Back to Top | Article Outline

GOOD PRACTICES AND LESSONS LEARNED

Good practices and lessons learned from integrating PMTCT services, particularly regarding upstream policy and health system practices to facilitate integration are presented on Box 3. Key lessons learnt include the following:

Back to Top | Article Outline

Good Policy and Health System Practices That Facilitate PMTCT Integration Cited Here...

  1. Foster political will and leadership to enable the policy and health system changes required for integration by gaining buy in from policy makers and managers overseeing PMTCT programs and the relevant related HIV SRHR, and ART and TB programs
  2. Develop thorough and sustainable integration strategies to explain how integrated services are to be organized and delivered and to carefully guide the process of restructuring health systems to support integration.
  3. Establish a coordination mechanism to enable communication, alignment of plans and budgets, and joint problem solving between the different line departments involved in service integration.
  4. Revise commodity management, monitoring, and evaluation to ensure any additional commodities are available in sufficient quantities to support newly integrated services and that systems are in place for facilitative supervision and evaluation of the impact of integrated service delivery.
  5. Support health providers and managers to be engaged in the process of restructuring services, to receive training to perform new tasks, and to adapt to changes in protocols, workload, and responsibilities.
  6. Inform and engage clients and communities to ensure that users of the services are aware of where to go for what services and to minimize potential stigma and discrimination.
Back to Top | Article Outline

Task Shifting and Task Sharing Are Essential for Successful Integration

Integration requires health workers to provide additional services that they initially may not be eligible, accustomed, or skilled to perform. These task shifting and task sharing frequently required changes in accreditation, prescribing authority, and training to enable a wider cadre of health workers to deliver interventions. In the Democratic Republic of Congo, nurses in primary care facilities were trained to deliver HIV and TB interventions with 98% agreement between nurses and physicians regarding decision making on antiretroviral therapy initiation and 95% agreement regarding the choice of antiretroviral therapy regimen.20 Antiretroviral therapy uptake by TB clients living with HIV rose from 17% when clients were referred for antiretroviral therapy to 67% under the integrated model, and mortality during TB treatment declined from 20% to 10%.

Back to Top | Article Outline

Health Information Systems Require Adjustment to Capture Integrated Service Delivery

Because integrated services are now being delivered at multiple points of care, health information systems have required adaptation to track clients (including mother–baby pairs) through the continuum of care. Although this is not necessarily a widespread practice elsewhere at this time, a program in Uganda has developed a special indicator to track retention of mother–baby pairs over 18 months. Health care providers trace mother–baby pairs through community follow-up, and facilities keep their charts together. As a result, retention of mother–baby pairs has increased from 2.2% to 60% in less than a year.36 In Swaziland, the registration form for antiretroviral therapy has been revised to include an entry on the fertility intentions of clients.37 In Malawi, the integration of antiretroviral therapy and PMTCT has required a revision of the monitoring and evaluation tools and reporting systems.

Back to Top | Article Outline

Integrating Services Require Availability and Joint Management of Commodities for HIV, SRH, and Other Services

Provision of integrated services for the 4 prongs has required an expanded, coordinated, and secure supply chain to provide HIV test kits, antiretroviral medicines for treatment and PrEP and postexposure prophylaxis, contraceptives, penicillin to treat syphilis, and supplies to detect and treat precursor lesions and early stage cervical cancer. In addition, integrated services would require greater attention to both pediatric and maternal TB, especially in high-TB prevalence regions.

Back to Top | Article Outline

Integration May Minimize Costs and Increase Efficiency Gains

Evidence on costs, potential cost-effectiveness, and cost efficiency of integrating HIV and SRHR services is fairly limited and conflicting, partly because of variations in models of integration and lack of comparison with vertical services. Data from Kenya and Swaziland show that gains in efficiency when integrating HIV and SRHR services may be achieved through better use of human and capital resources and increased demand.38 Efficiency gains from HIV and SRHR service integration are not guaranteed, relatively modest, and most likely to occur where fixed costs have been high and client uptake increases.39

A review of cost savings gained by integrating PMTCT interventions into antenatal care facilities (task-shifting antiretroviral therapy delivery to nurses and increasing coverage) and integrating family planning into HIV care in Malawi, Mozambique, and Uganda found that integrating both saved costs and improved HIV and SRH outcomes.40 A systematic review of the literature on cost and cost-effectiveness, based on cost per averted pregnancy, concluded that integrating PMTCT and MNCH services was cost effective, especially when offering HIV counseling and testing in antenatal care and family planning at antiretroviral therapy sites. Evidence is limited on whether this observation holds true at scale and on the relative efficiency of different models of integration.41 A study in Kenya corroborated the cost-effectiveness of integrating family planning into HIV treatment clinics.42 The cost benefits of integrated services accrue through economies of scope and scale, time savings for clients, and lower opportunity costs because of better health status. However, additional studies are still needed to provide more robust cost savings of integration.

Back to Top | Article Outline

Integration Is Not a Panacea for Underlying Inadequate Health Systems but It Can Potentially Improve Service Delivery

Although integrating services can improve health provider productivity and client experiences, it can also have unintended consequences, such as overloading staff and creating longer client waiting times.19,33 In Zambia, merging the antiretroviral therapy clinic with the outpatient department led to a 32% increase in waiting times for outpatient department clients and a 36% increase for antiretroviral therapy clients, although the delays were partly attributable to the model of integration used, inadequate staffing levels, and other variables.43 Despite largely favorable results in rural Kenya, where HIV treatment was integrated into antenatal care, provider workload increased and any potentially longer visits for women living with HIV (compared with other antenatal care clients) added risk of inadvertent disclosure of HIV status.44

Other experiences with integrated service delivery have been more favorable. In Namibia, client wait times decreased and provider productivity increased after integration of services (Box 1).27 In several other countries, integrated service delivery reportedly reduced stigma and discrimination.27

Back to Top | Article Outline

DISCUSSION

Every additional step in accessing integrated PMTCT services—such as being seen by multiple providers during one visit, being referred on-site or to off-site clinics, or returning for services offered only on certain days—can place hurdles in the path of women and their infants. The Global Plan priority countries are overcoming some of these barriers by increasingly offering integrated services to meet the multiple health needs of clients simultaneously. Enabling nurses and midwives to initiate and manage long-term antiretroviral therapy in MNCH settings was a significant game changer in expanding access to PMTCT for pregnant women living with HIV: by 2015, 80% of pregnant women living with HIV in these countries were receiving more effective antiretroviral regimens.27 In contrast, primary prevention of HIV for pregnant and breastfeeding women as well as prevention and treatment of maternal and peditric TB, is not yet adequately programmed as part of PMTCT integration.

Integrating PMTCT services has shown potential for improving coverage, scope, and quality of services, reducing loss to follow-up, and using resources more efficiently.45,46 In Eastern and Southern Africa, integration of HIV and SRHR services has been advancing steadily,27 with governments developing guidance for national scale-up.47–50 The progressive WHO shift toward a “treat-all” approach can be expected to further accelerate service integration. Validation of “dual elimination” of mother-to-child transmission of HIV and syphilis also is likely to catalyze further integration with sexually transmitted infection prevention, treatment, and postpartum follow-up.

Policy, health systems, and financing considerations are paramount to supporting integrated service delivery.3 Informed and even visionary leadership is essential to forge partnerships among complex and often territorial separate programs, particularly under current funding constraints. A systematic study is needed to rigorously assess the impact of integrating PMTCT more broadly into existing health services, including cost implications, the effect on wider health systems, and outcomes related to health, stigma, and discrimination.

Back to Top | Article Outline

REFERENCES

1. UNAIDS. Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive. Geneva, Switzerland: UNAIDS; 2011.
2. Xia J, Rutherford S, Ma Y, et al. Obstacles to the coordination of delivering integrated prenatal HIV, syphilis and hepatitis B testing services in Guangdong: using a needs assessment approach. BMC Health Serv Res. 2015;15:117.
3. Hope R, Kendall T, Langer A, et al. Health systems integration of sexual and reproductive health and HIV services in sub-Saharan Africa: a scoping study. J Acquir Immune Defic Syndr. 2014;67(suppl 4):S259–S270.
4. Tudor CL, Van Velthoven MHMMT, Brusamento S, et al. Integrating prevention of mother-to-child HIV transmission programs to improve uptake: a systematic review. PLoS One. 2012;7:e35268.
5. World Health Organization. Technical Consultation on the Integration of HIV Interventions Into Maternal, Newborn, and Child Health Services. Report of a WHO Meeting, Geneva, Switzerland, April 5–7, 2006. Geneva, Switzerland: WHO, 2006. Available at: http://apps.who.int/iris/bitstream/10665/69767/1/WHO_MPS_08.05_eng.pdf. Accessed October 2016.
6. Atun RA, Bennett S, Duran A. When Do Vertical (Stand-Alone) Programmes Have a Place in Health Systems? Policy Brief. Geneva, Switzerland: World Health Organization; 2008.
7. Druce N, Nolan A. Seizing the big missed opportunity: linking HIV and maternity care services in sub-Saharan Africa. Reprod Health Matters. 2007;15:190–201.
8. World Health Organization (WHO). PMTCT Strategic Vision, 2010–2015. Preventing Mother-to-child Transmission of HIV to Reach the UNGASS and Millennium Development Goals. Geneva, Switzerland: WHO; 2010.
9. Pfeiffer J, Montoya P, Baptista AJ, et al. Integration of HIV/AIDS services into African primary health care: lessons learned for health system strengthening in Mozambique—a case study. J Int AIDS Soc. 2010;13:3.
10. Nkwo PO. Prevention of mother to child transmission of human immunodeficiency virus: the Nigerian perspective. Ann Med Health Sci Res. 2012;2:56–65.
11. World Health Organization (WHO). HIV Infection in Infants. Report of a WHO Meeting, Morges, Switzerland, March 20–22, 2002. Geneva, Switzerland: WHO; 2003.
12. UNICEF/Ngashi. Monitoring Progress on the Implementation of Programs to Prevent Mother to Child Transmission of HIV. PMTCT Report Card 2005. New York, NY: UNICEF, 2005.
13. World Health Organization (WHO). Prevention of Mother-to-child Transmission (PMTCT). Briefing Note 1. Geneva, Switzerland: WHO; 2007.
14. The Interagency Task Team for the Prevention and Treatment of HIV Infection in Pregnant Women, Mothers, and Children (IATT). Preventing HIV and Unintended Pregnancies: Strategic Framework 2011–2015. IATT; 2012. Available at: http://http://www.unfpa.org/sites/default/files/pub-pdf/V2_web_P1P2_framework%2022.8.12.pdf. Accessed October 2016.
15. Rutenberg N, Baek C. Field experiences integrating family planning into programs to prevent mother-to-child transmission of HIV. Stud Fam Plann. 2005;36:235–245.
16. Kennedy CE, Spaulding AB, Brickley DB, et al. Linking sexual and reproductive health and HIV interventions: a systematic review. J Int AIDS Soc. 2010;13:26.
17. Inter-agency Working Group (IAWG). SRH & HIV Linkages Resource Pack [Web Page]. IAWG on SRH & HIV Linkages; 2012. Available at: http://www.srhhivlinkages.org. Accessed October 2016.
18. The Integration Initiatives. Integra Initiative [Homepage]. The Integration Initiatives; 2014. Available at: http://www.integrainitiative.org. Accessed November 2016.
19. Sweeney S, Obure CD, Terris-Prestholt F, et al. The impact of HIV/SRH service integration on workload: analysis from the Integra Initiative in two African settings. Hum Resour Health. 2014;12:42.
20. Van Rie A, Patel MR, Nana M, et al. Integration and taskshifting for TB/HIV care and treatment in highly-resource scarce settings: one size may not fit all. J Acquire Immune Defic Syndr. 2014;65:e110–e117.
21. The Interagency Task Team for the Prevention and Treatment of HIV Infection in Pregnant Women, Mothers, and Children (IATT), United Nations Population Fund (UNFPA), International Planned Parenthood Federation (IPPF), , et al. Eliminating mother-to-child transmission of HIV and keeping their mothers alive: job aid for health care workers [Web resource]. Available at: https://http://www.unfpa.org/sites/default/files/resource-pdf/IATT_EMTCTJobAid_WEB_0.pdf. Accessed October 2016.
22. Liambila W, Askew I, Ayisi R, et al. Feasibility, Acceptability, Effect and Cost of Integrating Counseling and Testing for HIV Within Family Planning Services in Kenya. FRONTIERS Final Report. Washington, DC: Population Council; 2008.
23. Bradley H, Bedada A, Tsui A, et al. HIV and family planning service integration and voluntary HIV counseling and testing client composition in Ethiopia. AIDS Care. 2008;20:61–71.
24. ProgramProgramUNAIDS. 2015 Global Plan Progress Report: Towards the Elimination of New HIV Infections Among Children and Keeping Their Mothers Alive. Geneva, Switzerland: UNAIDS; 2015.
25. UNAIDS, United States Presidents Emergency Plan for AIDS Relief (PEPFAR), United Nations Children's Fund (UNICEF), , et al. On the Fast-Track to an AIDS-Free Generation: The Incredible Journey of the Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive. Geneva, Switzerland: UNAIDS; 2016.
26. FHI360, Preventative Technologies Agreement (PTA), United States Agency for International Development (USAID). Integrating Family Planning Into HIV Programs: Evidence-Based Practices. Durham, NC: FHI360; 2014.
27. ProgramProgramUNAIDS, United Nations Population Fund (UNFPA), European Union, Swedish International Development Coordination Agency (SIDA), Norwegian Agency for Development Cooperation (norad). Linking Sexual and Reproductive Health and Rights and HIV in Southern Africa. Demonstration Projects in Seven Southern African Countries Have Scaled up Effective Models for Strengthening Integrated SRH and HIV Policies, Systems, and Service Delivery Mechanisms. Johannesburg, South Africa: UNFPA ESARO; 2015. Available at: http://esaro.unfpa.org/sites/default/files/pub-pdf/Regional%20booklet%20final%20-%20Linking%20SRHR%20%26%20HIV%20in%20Southern%20Africa.pdf. Accessed December 2016.
28. Grossman D, Onono M, Newmann S, et al. Integration of family planning services into HIV care and treatment in Kenya: a cluster-randomized trial. AIDS. 2013;27(suppl 1):S77–S85.
29. Hounton S, Winfrey W, Barros A, et al. Patterns and trends of postpartum family planning in Ethiopia, Malawi, and Nigeria: evidence of missed opportunities for integration. Glob Health Action. 2015;8:29738.
30. World Health Organization: Antiretroviral Therapy for HIV Infection in Adults and Adolescents: Recommendations for a Public Health Approach. 2010 Rev. Geneva, Switzerland, WHO, 2010. Available at: http://apps.who.int/iris/bitstream/10665/44379/1/9789241599764_eng.pdf. Accessed January 20, 2017.
31. Kalua T, Barr BT, van Oosterhout JJ, et al: Lessons learned from option B+ in the evolution towards “test and start” from Malawi, Cameroon and the United Republic of Tanzania. J Acquire Immune Defic Syndr. 2017;75(suppl 1):S43–S50.
32. Schouten EJ, Jahn A, Midiani D, et al. Prevention of mother-to-child transmission of HIV and the health-related Millennium Development Goals: time for a public health approach. Lancet. 2011;378:282–284.
33. Myer L, Phillips T, Zerbe A, et al. Integration of postnatal services improves MCH and ART outcomes: a randomised trial. Oral Presentation, CROI, Seattle, WA, 2017.
34. Office of the United States Global AIDS Coordinator. Congressional Budget Justification Supplement, FY 2016. Washington DC: PEPFAR, 2016. Available at: https://http://www.pepfar.gov/documents/organization/241600.pdf. Accessed December 2016.
35. Wiegert K, Dinh TH, Mushavi A, et al. Integration of prevention of mother-to-child transmission of HIV (PMTCT) postpartum services with other HIV care and treatment services within the maternal and child health setting in Zimbabwe, 2012. PLoS One. 2014;9:e98236.
36. Nsubuga-Nyombi T, Karamagi-Nkolo E, Draru J, et al. Improving Retention of Mother–Baby Pairs: Tested Changes and Guidance From Uganda. Bethesda, MD: University Research Co. LLC; 2014.
37. Government of Swaziland, World Health Organization (WHO), United Nations Population Fund (UNFPA), UNAIDS, International Planned Parenthood Federation (IPPF). Gateways to Integration: A Case Study From Swaziland. Geneva, Switzerland: WHO, UNFPA, UNAIDS, IPPF; 2012.
38. Obure CD, Sweeney S, Darsamo V, et al. The costs of delivering integrated HIV and sexual reproductive health services in limited resource settings. PLoS One. 2015;10:e0124476.
39. Obure CD, Guinness L, Sweeney S, et al. Does integration of HIV and SRH services achieve economies of scale and scope in practice? A cost function analysis of the Integra Initiative. Sex Transm Infect. 2016;92:130–134.
40. USAID. Cost-Effectiveness of Integrating PMTCT and MNCH Services: An Application of the LiST Model for Malawi, Mozambique, and Uganda. DHS Occasional Paper No. 7. Calverton, MD: ICF International; 2013. Available at: https://dhsprogram.com/pubs/pdf/OP7/OP7.pdf. Accessed October 2016.
41. Dehne K, Greener R, Maier CB, et al. Cost and efficiency of integrating HIV/AIDS services into other health services: a systematic review of evidence and experience. Sex Transm Infect. 2012;88:85–99.
42. Shade S, Kevany S, Onono M, et al. Integration of family planning and HIV services is feasible, inexpensive to implement, and cost-efficient in the Kenyan setting, and thus supports current Kenyan integration policy. AIDS. 2013;27(suppl 1):S87–S92.
43. Deo S, Topp SM, Garcia A, et al. Modeling the impact of integrating HIV and outpatient health services on patient waiting times in an urban health clinic in Zambia. PLoS One. 2012;7:e35479.
44. Winestone LE, Bukusi EA, Cohen CR, et al. Acceptability and feasibility of integration of HIV care services into antenatal clinics in rural Kenya: a qualitative provider interview study. Glob Public Health. 2012;7:149–163.
45. World Health Organization (WHO), United Nations Children's Fund (UNICEF), Elizabeth Glaser Pediatric AIDS Foundation. The Double Dividend: A Synthesis of Evidence for Action to Improve Survival of HIV “Exposed” Children in the Era of EMTCT and Renewed Child Survival Campaigns. New York, NY: UNICEF; 2013. Available at: http://http://www.childrenandaids.org/css/Synthesis_of_Evidence.pdf. Accessed December 2016.
46. Suthar AB, Hoos D, Beqiri A, et al. Integrating antiretroviral therapy into antenatal care and maternal and child health settings: a systematic review and meta-analysis. Bull World Health Organ. 2013;91:46–56.
47. Southern African Development Community (SADC). Minimum Standards for the Integration of HIV and Sexual and Reproductive Health in the SADC Region. Gabarone, Botswana: SADC; 2015. Available at: https://resourcecentre.savethechildren.net/sites/default/files/documents/sadc_minimum_package_of_services.pdf. Accessed March 13, 2017.
48. Kenya National AIDS & STI Control Programme and Reproductive and Maternal Health Services Unit. Integrating Reproductive Health and HIV Care and Treatment Services: A Toolkit for Health Providers. Nairobi, Kenya: Ministry of Health; 2016. Avaialble at: http://toolkit.srhhivlinkages.org/content/cat2/integrating-rh-and-hiv-services-toolkit-for-service-providers.pdf. Accessed January 30, 2017.
49. Government of Namibia, European Union (EU), United Nations Population Fund (UNFPA), ProgramProgramUNAIDS, and World Health Organization (WHO). Namibian National Guidelines on Health Service Integration: Sexual and Reproductive Health, HIV and Other Services at Primary Health Care. Windhoek, Namibia: Government of Namibia; 2016. Available at: http://toolkit.srhhivlinkages.org/content/cat3/srhr-hiv-and-other-services-guideline.pdf. Accessed January 23, 2017.
50. Government of Zambia, United Nations Population Fund (UNFPA), European Union (EU), Swedish International Development Coordination Agency (SIDA), Norwegian Agency for Development Cooperation (norad), ProgramProgramUNAIDS. Zambia National Guidelines for SRH, HIV, and GBV Services Integration 2015.
51. UNAIDS, European Union (EU), Norwegian Agency for Development Cooperation (norad), Swedish International Development Coordination Agency (SIDA), United Nations Population Fund (UNFPA), Government of Namibia. Namibia: Enhancing Efficiencies in Integrated Service Delivery. Johannesburg, South Africa: UNFPA; 2015. Available at: http://http://www.integrainitiative.org/wp/wp-content/uploads/2015/04/UNFPA-onepager-Namibia.pdf. Accessed March 13, 2017.
52. Government of Namibia Ministry of Health and Social Services. National Guidelines on Health Service Integration: Sexual Reproductive Health, HIV and Rights and Other Services. Windhoek, Namibia: Government of Namibia; 2016.
53. Swaziland Ministry of Health, European Union (EU), UNAIDS, United Nations Population Fund (UNFPA). Patient and Provider Satisfaction Survey on Integrated SRH/HIV Services in Swaziland's 5 Model Centers of Excellence Facilities. 2013. Available at: http://http://www.integrainitiative.org/wp/wp-content/uploads/2015/04/Swaz-patient-and-provider-Satisfaction-Survey-Dec2013.pdf. Accessed January 30, 2017.
    Keywords:

    HIV; integration; prevention of mother-to-child transmission (PMTCT); sexual and reproductive health (SRH); maternal, newborn, and child health (MNCH)

    Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.