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The ACCLAIM Study aimed to assess the effect of a package of community interventions on the demand for, uptake of, and retention of HIV-positive pregnant/postpartum women in maternal and child health (MCH) and prevention of mother-to-child HIV transmission (PMTCT) services. The study occurred from 2013 to 2015 in Eswatini, Uganda, and Zimbabwe. The three interventions were: (1) a social learning and action component for community leaders, (2) community days, and (3) peer discussion groups. Household cross-sectional surveys on community members' MCH and PMTCT knowledge, attitudes, and beliefs were analyzed pre- and post-intervention, using MCH, HIV stigma, and gender-equitable men (GEM) indicators. We used t-tests to measure the significance of mean pre- vs. post-intervention score changes stratified by gender within each intervention arm and generalized linear models to compare mean score changes of the cumulative intervention arms with the community leaders-only intervention. Response rates were over 85% for both surveys for men and women, with a total of 3337 pre-intervention and 3162 post-intervention responses. The combined package of three interventions demonstrated a significantly greater increase in MCH scores for both women (diff = 1.34, p ≤ 0.001) and men (diff = 2.03, p < 0.001). The arms that included interventions for both community leader engagement and community days (arms 2 and 3)led to a greater increase in mean GEM scores compared to the community leader engagement intervention alone (arm 1), for both women (diff = 1.32, p = 0.002) and men (diff = 1.37, p = 0.004). Our findings suggest that a package of community interventions may be most effective in increasing community MCH/HIV knowledge and improving gender-equitable norms.

Background: Development of country plans for prevention of mother-to-child HIV transmission (PMTCT), including expansion of comprehensive, integrated services, was key to Global Plan achievements., Approaches: Use of the PMTCT cascade, an evolving series of sequential steps needed to maximize the health of women and HIV-free survival of infants, was critical for development and implementation of PMTCT plans. Regular review of cascade data at national/subnational levels was a tool for evidence-based decision making, identifying areas of greatest need at each level, and targeting program interventions to address specific gaps. Resulting improvements in PMTCT service delivery contributed to success. Populating the cascade highlighted limitations in data availability and quality that focused attention on improving national health information systems., Limitations: Use of aggregate, cross-sectional data in the PMTCT cascade presents challenges in settings with high mobility and weak systems to track women and children across services. Poor postnatal follow-up and losses at each step of the cascade have limited use of the cascade approach to measure maternal and child health outcomes beyond the early postnatal period., Lessons Learned: A cascade approach was an effective means for countries to measure progress, identify suboptimal performance areas, and be held accountable for progress toward achievement of Global Plan goals. Using the cascade requires investment of time and effort to identify the type, source, and quality of data needed as programs evolve. Ongoing review of cascade data, with interventions to address discontinuities in the continuum of care, can translate across health areas to improve health care quality and outcomes.

Background: Swaziland has one of the highest HIV prevalence rates in sub-Saharan Africa, 26 % of the adult population is infected with HIV. The prevalence is highest among pregnant women, at 41.1 %. According to Swaziland's prevention of mother-to-child transmission (PMTCT) guidelines, approximately 50 % of pregnant women are eligible for antiretroviral therapy (ART) by CD4 criteria (<350 cells/ml). Studies have shown that most mother-to-child transmission and postnatal deaths occur among women who are eligible for ART. Therefore, ensuring that ART eligible women are initiated on ART is critical for PMTCT and for mother and baby survival. This study provides insight into the challenges of lifelong ART initiation among pregnant women under Option A in Swaziland. We believe that these challenges and lessons learned from initiating women on lifelong ART under Option A are relevant and important to consider during implementation of Option B+., Methods: HIV-positive, treatment-eligible, postpartum women and nurses were recruited within maternal and child health (MCH) units using convenience and purposive sampling. Participants came from both urban and rural areas. Focus group discussions (FGDs) and structured interviews using a short answer questionnaire were conducted to gain an understanding of the challenges experienced when initiating lifelong ART. Seven FGDs (of 5-11 participants) were conducted, four FGDs with nurses, two FGDs with women who initiated ART, and one FGD with women who did not initiate ART. A total of 83 interviews were conducted; 50 with women who initiated ART and 33 with women who did not initiate. Data collection with the women was conducted in the local language of SiSwati and data collection with the nurses was done in English. FGDs were audio-recorded and simultaneously transcribed and translated into English. Analysis was conducted using thematic analysis. Transcripts were coded by two researchers in the qualitative software program MAXqda v.10. Thematic findings were illustrated using verbatim quotes which were selected on the basis of being representative of a specific theme. The short-answer interview questionnaire included specific questions about the different steps in the woman's experience initiating ART; therefore the responses for each question were analyzed separately., Results: Findings from the study highlight women feeling overwhelmed by the lifetime commitment of ART, feeling "healthy" when asked to initiate ART, preference for short-course prophylaxis and fear of side effects (body changes). Also, the preference for nurses to determine on an individual basis the number of counseling appointments a woman needs before initiating ART, more information about HIV and ART needed at the community level, and the need to educate men about HIV and ART., Conclusion: Women face a myriad of challenges initiating lifelong ART. Understanding women's concerns will aid in developing effective counseling messages, designing appropriate counseling structures, understanding where additional support is needed in the process of initiating ART, and knowing who to target for community level messages.

Background: Efforts to scale up and improve programs for prevention of mother-to-child transmission of HIV (PMTCT) have focused primarily at the health facility level, and limited attention has been paid to defining an effective set of community interventions to improve demand and uptake of services and retention. Many barriers to PMTCT are also barriers to pregnancy, childbirth, and postnatal care faced by mothers regardless of HIV status. Demand for maternal and child health (MCH) and PMTCT services can be limited by critical social, cultural, and structural barriers. Yet, rigorous evaluation has shown limited evidence of effectiveness of multilevel community-wide interventions aimed at improving MCH and HIV outcomes for pregnant women living with HIV. We propose to assess the effect of a package of multilevel community interventions: a social learning and action component, community dialogues, and peer-led discussion groups, on the demand for, uptake of, and retention of HIV positive pregnant/postpartum women in MCH/PMTCT services., Methods/design: This study will undertake a three-arm randomized trial in Swaziland, Uganda, and Zimbabwe. Districts/regions (n = 9) with 45 PMTCT-implementing health facilities and their catchment areas (populations 7,300-27,500) will be randomly allocated to three intervention arms: 1) community leader engagement, 2) community leader engagement with community days, or 3) community leader engagement with community days and male and female community peer groups. The primary study outcome is HIV exposed infants (HEIs) returning to the health facility within 2 months for early infant diagnosis (EID) of HIV. Secondary study outcomes include gestational age of women attending for first antenatal care, male partners tested for HIV, and HEIs receiving nevirapine prophylaxis at birth. Changes in community knowledge, attitudes, practices, and beliefs on MCH/PMTCT will be assessed through household surveys., Discussion: Implementation of the protocol necessitated changes in the original study design. We purposively selected facilities in the districts/regions though originally the study clusters were to be randomly selected. Lifelong antiretroviral therapy for all HIV positive pregnant and lactating women, Option B+, was implemented in the three countries during the study period, with the potential for a differential impact by study arm. Implementation however, was rapidly done across the districts/regions, so that there is unlikely be this potential confounding. We developed a system of monitoring and documentation of potential confounding activities or actions, and these data will be incorporated into analyses at the conclusion of the project. Strengthens of the study are that it tests multilevel interventions, utilizes program as well as study specific and individual data, and it is conducted under "real conditions" leading to more robust findings. Limitations of the protocol include the lack of a true control arm and inadequate control for the potential effect of Option B+, such as the intensification of messages as the importance of early ANC and male partner testing., Trial Registration: ClinicalTrials.gov (study ID: NCT01971710) Protocol version 5, 30 July 2013, registered 13 August 2013.

Objective: To maximize prevention of mother-to-child transmission of HIV (PMTCT) effectiveness and increase identification of HIV status in maternity units in Swaziland., Design: With a quasi-experimental design, 3 maternity units were randomly assigned to the training intervention and 3 units were controls., Methods: Targeted on-site training was provided to nurse-midwives in intervention sites. HIV status was recorded with testing offered to women presenting with unknown and distant negative status. Cord blood was obtained and tested for HIV antibodies and presence of nevirapine as a marker of PMTCT intervention coverage. Contingency tables and χ² tests were used to test for associations between frequencies of events., Results: Of the 2444 enrolled women, 215 (9%) arrived in maternity with unknown status and 1398 (58%) had tested HIV negative in antenatal clinic. Significantly more HIV-negative women (45%) and women with unknown status (96%) in intervention sites were tested compared with similar women in control sites, 14% and 65%, respectively (P < 0.0001 for both). Nevirapine coverage in HIV-positive cord blood was significantly higher in intervention sites (80%) than in control sites (69%, P < 0.0001). Cumulative HIV incidence was 4% with an incidence rate of 16.8 per 100 person-years. Antiretroviral prophylaxis coverage in seroconverters was significantly higher in intervention sites 54% (13 of 24) than the control group [26% (9 of 34), P = 0.03]., Conclusions: In high HIV prevalence settings, such as Swaziland, the incidence of HIV during pregnancy is high. An on-site training intervention for maternity nurses significantly increases the identification of HIV infection and maximizes the provision of PMTCT interventions.