Abstract

Background: The "Test & Treat" approach, also called option B+, using combination antiretroviral treatment (cART) for prevention of mother-to-child transmission (PMTCT) has been very effective in controlled clinical trials in resource-limited settings. We report on our experiences with implementing this approach at primary healthcare settings in Katanga province, Democratic Republic of Congo (DRC). The objective of this study was to evaluate « Test & Treat » approach for PMTCT interventions implemented between September 2013 and June 2015 at local health centers (LHC) in the DRC, in order to learn on the challenges for its scale up at national level. Methods: We conducted a cross-sectional study. In September 2015, data related to the coverage of "Test & Treat" approach for PMTCT interventions were collected using two techniques: interview and analysis of routinely collected medical data. Interview was conducted with PMTCT focal points at selected LHC using a questionnaire developed and tested on the following: i) administrative status of health facility, ii) number of cART prescribers, as well as iii) availability of renal and liver function tests. The analysis of medical records (registers, patient's medical records) included data of patients recorded between September 2013 and June 2015 according to PMTCT cascades. Data were analyzed using Statav13.0 (College Station, TX). Logistic regression was used to identify factors associated with initiation of cART on the same day with tests for all variables having p-value less than or equal to 10% in univariable analysis. The adjustment of the model was made by using the Hosmer and Lemeshow test. The odds ratio adjusted and confident interval at 5% were calculated. The significance level was 5%. Results: Of 19,932 pregnant women who received PMTCT services between October 2013 and April 2015 at 85 LHC, 5,381 (27%), 12,557 (63%), 1,395 (7%), and 598 (3%) consulted during the first, second, and third trimester of pregnancy and in labor, respectively. In total, 569 (2.9%) and 19,633 (98.5%) were tested positive and negative for HIV, respectively. All 569 pWLHIV received cotrimoxazole prophylaxis (CP); 557 (97.9%) received cART; blood samples were collected from 373 (65.6%) for kidney and liver function (K&L) tests, and 128 (22.5%) underwent screening for tuberculosis co-infections. Women in rural areas were twice as likely to receive cART on the day of HIV diagnosis compared to those in urban areas (prevalence risk ratio [PRR] = 2.0; 95% CI = 1.7-2.3; p < 0.001); a similar trend was observed for those who were attended by one cART prescriber at antenatal care compared to those attended by many prescribers (PRR = 0.4; 95% CI = 0.1-0.5; p < 0.001). A longer time gap of K&L results delayed cART on the day of HIV diagnosis (PRR = 0.3; 95% CI = 0.01-0.5; p < 0.001). At 6 to 10 weeks of age, 3.7% (4/108) infants were HIV positive. At 12 months of age; 7.5% (37/493) infants were HIV positive, with 6.8% (22/322) in urban versus 8.8% (15/171) in rural areas (p = 0.47). Conclusions: The "Test & Treat" approach can be well implemented at LHC in DRC with most pWLHIV being identified and administered cART and CP on the same day; and < 10% instead of < 5% as targeted by the global plan for the elimination mother to child transmission, MTCT rates were likely to be observed by 12 months of age. However, retention in care and infant HIV diagnosis services are challenging.

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