Mapping evidence of interventions and strategies to bridge the gap in the implementation of the prevention of mother-to-child transmission of HIV programme policy in sub-Saharan countries: A scoping review

Background Prevention of mother-to-child transmission (PMTCT) of HIV is a life-saving public health intervention. Sub-Saharan African (SSA) countries have made significant progress in the programme, but little is known about the strategies used by them to eliminate mother-to-child transmission of HIV. Aim To map evidence of strategies and interventions employed by SSA in bridging the implementation gap in the rapidly changing PMTCT of HIV programme policy. Methods Electronic search of the databases MEDLINE, PubMed and SABINET for articles published in English between 2001 and August 2016. Key words included ‘Sub-Saharan African countries’, ‘implementation strategies’, ‘interventions to bridge implementation gap’, ‘prevention of mother-to-child transmission of HIV’ and ‘closing implementation gap’. Results Of a total of 743 articles, 25 articles that met the inclusion criteria were included in the study. Manual content analysis resulted in the identification of three categories of strategies: (1) health system (referral systems, integration of services, supportive leadership, systematic quality-improvement approaches that vigorously monitors programme performance); (2) health service delivery (task shifting, networking, shared platform for learning, local capacity building, supportive supervision); as well as (3) community-level strategies (community health workers, technology use – mHealth, family-centred approaches, male involvement, culturally appropriate interventions). Conclusion There are strategies that exist in SSA countries. Future research should examine multifaceted scientific models to prioritise the highest impact and be evaluated for effectiveness and efficiency.


Introduction
Sub-Saharan African (SSA) countries are highly burdened by HIV. 1 The children are at risk of transmission of HIV from mother-to-child, which is a major public health concern. The programme 'prevention of mother-to-child transmission (PMTCT) of HIV' is aimed at addressing this problem. It has been demonstrated that the risk of mother-to-child transmission (MTCT) of HIV can be reduced by implementing key interventions, especially in resource limited settings. Countries are working towards 2,3 meeting the Global Plan targets of the elimination of MTCT of HIV. Also, eradicating the HIV epidemic by 2020 remains the key target of the Sustainable Development Goal on health and well-being. 1,3,4,5 Sub-Saharan African countries have demonstrated significant progress in the scaling up of PMTCT. The number of new HIV infections among children had significantly dropped from 350 000 in 2009 to less than 199 000 by 2013, which is a 43% decline in SSA countries. However, this is not in tune with the 90% reduction aimed for in the Global Plan (2011)(2012)(2013)(2014)(2015). 4 Disparities exist in the reduction of new HIV infection in children in the SSA countries. It is clear that the progress is slow, and efforts to accelerate progress are needed for countries to achieve the universal targets of 90-90-90. 1,3,4,5,6 Much evidence exists demonstrating barriers to PMTCT programme policy implementation, 2,7,8,9,10,11,12,13 meant to save lives. While World Health Organization (WHO) had recommendations for countries to adopt including Option B+ which promotes universal life-long antiretroviral treatment (ART) for all, crucial barriers to successful implementation remain. 4,9,14,15 Strategies are employed by the SSA countries to bridge the implementation gap for the PMTCT programme. As appreciation of the impact of implementation of policy develops interest, it is crucial that the evidence of such interventions is identified and mapped out.
The aim of the scoping was to map the existing literature on the interventions and strategies applied in the SSA countries to close PMTCT of HIV policy implementation.

Search strategy
The scoping review involved a comprehensive systematic literature search in MEDLINE, PubMed, SABINET databases, including the reference list of included studies and key websites from WHO and UNAIDS. Two independent reviewers (WH and ZL) screened all titles and abstracts using predetermined inclusion and exclusion criteria, reviewed full text articles for inclusion, with disagreements settled by third and fourth reviewers (BN, JN) to ensure reliability of findings. The keyword search included 'sub-Saharan African countries, implementation gap strategies, interventions to bridge implementation gap, prevention of mother-to-child transmission of HIV, closing implementation gap for PMTCT'.
The search was limited to English language publications between 2001 and August 2016. Studies were included if they reported on interventions or strategies for bridging implementation gap for PMTCT of HIV health programme policy in SSA countries; if they were fully accessible; and if they dealt with public health setting strategies or communitylevel interventions.
We excluded studies that were not published in English; not conducted in SSA countries, did not provide the setting; did not provide strategies; focused their intervention on programmes other than PMTCT; had inaccessible full texts; had inappropriate methodology; had comments or debates; were published prior to 2001.

Data extraction and analysis
The search criteria used PRISMA 2009 diagram tool 16 to map relevant searched articles (see Figure 2). A standardised data extraction form was used to guide eligibility of extracted studies edited from PICOS framework (Population, Intervention, Comparison, Outcome, Study design) which charted information on author and year, study design, population, % of population, intervention, aim of the study as well as the key findings including recommendations if any (see Table 1). The review was not limited to study designs. Manual content analysis was used to identify key categories and reporting on key findings. Mixed Method Appraisal Tool (MMAT) was used for quality assessment of included studies. 17,18 Ethical consideration This article is part of a PhD thesis, which is being currently conducted in accordance with permission from the ethics committee of the University of KwaZulu-Natal (UKZN) BREC (Biomedical Research Ethics Council), under the protocol reference number BE112/14.

Review results
The three-step study selection process for this scoping review comprised (1) first step: database search using keywords and title screening that returned 734 articles; 11 additional records were identified through reference lists and websites for WHO and UNAIDS. A total of 329 records after exclusion criteria, duplicates and non-English records were excluded; (2) second step: screening of titles and abstracts identified 73 records for full text review after exclusion of 256 papers which were either not conducted in SSA countries or reported on strategies or interventions for other health programmes and not for the PMTCT programme; (3) third step was full article screening, done in duplicate on 73 records, which resulted in 44 records being excluded for providing insufficient information; no description of interventions or strategies of interest; the full article not being accessible; for being in comment or debate form of report and conducted prior to 2001. This resulted in 29 records assessed for quality using MMAT tool checklist; however, a total of four articles were excluded for reasons such as inappropriate methodology or for not providing key findings (report on a protocol for randomised control trial). Average time spent critically appraising one article was 15 minutes. At the end of the final review and assessment, 25 eligible studies were included for final analysis. Details related to the search are provided in the PRISMA flow diagram (see Table 1). 19,20,21 Papers were mainly from six specific countries as well as from studies done across SSA countries as follows: South Africa (n = 8); Nigeria (n = 2); Uganda (n = 2); Malawi (n = 3); and a study done in three different countries of Malawi, Nigeria and Zimbabwe (n = 1), including studies done in SSA countries (n = 9) not specifically in one country. Majority of studies conducted in SSA countries were systematic reviews (n = 9), studies reporting on operational research (n = 3), qualitative studies (n = 6), quantitative studies (n = 4) and record review studies (n = 3). There were neither randomised controlled trial studies nor studies of mixed methods.

Types of strategies
Studies reported on the various stages of the implementation of PMTCT of HIV programmes by SSA countries ranging from the use of Option B to that of Option B+ as recommended by WHO. 3,6 After content analysis, the three most significant strategies and interventions that were in line with our objectives and inclusion criteria were categorised as follows: health service delivery, community-based interventions and health system strategies (see Figure 1).   ANC, antenatal clinic; ART, anti-retroviral treatment; CHNRI, Child Health Nutrition Research Initiative; LFTU, lost to follow up; IR, implementation research; MCH, maternal and child health; mHealth, mobile health; NVP, nevirapine; PCR, polymerase chain reaction; PICT, provider-initiated counselling and testing; PMTCT, prevention of mother-to-child transmission of HIV; RTCs, randomised controlled trials SSA, sub-Saharan Africa.

Health service delivery strategies
The common strategies reported included shared platform for learning and decision-making among stakeholders, 22 health service improvement of processes 2,23,24 and data-driven qualityimprovement approach which was mainly reported in South Africa. 25,26,27,28 This approach included health workers forming information teams to discuss issues relating to performance, forming learning networks which also promote shared learning, and discussing changes and planning for implementation.
There were studies that reported on strengthening of integration of PMTCT services into maternal health programme as well as clear role clarifications among the implementers 8,10,29,30 ; reinforcement of provider-initiated counselling and testing services by health workers to improve uptake 31 which is also linked to task shifting. Another approach for assisting in bridging the gap of PMTCT implementation is monitoring individual infants to determine the reason for transmission so that interventions can be targeted at  the barriers. 32 This, according to the study, can reveal specific barriers to be addressed for countries to get to zero infections.

Community-based strategies
It was common among assessed articles that the consideration of context and settings remained crucial, especially in SSA countries. 11,12,33,34 The reality on the ground is seen as one of the major barriers to implementation of prevention programmes such as the PMTCT programme; hence, strategies should be tailor-made to cater to such barriers. The importance of community involvement in bridging the gap in policies remains crucial. 21,35,36,37 There were articles that considered the promotion of disclosure of HIV infection in ensuring that communities are supported in the programme. 12 According to health care workers, failure to disclose can result in poor support. Owing to the fact that the programme needs communities to take part for its success, linkage between public health facilities and communities was seen as one strategy to close gaps in implementation.
Some models included the community care-givers, strengthened the linkages and the referral system between communities and health facilities 37,38,39 as well as made communities aware through community sensitisation models, including conducting campaigns in communities to create awareness and to address stigma which is reported as a barrier in communities. 34,37,40 In the inclusion of families using family-centred approach 41 , male involvement 36,38 was identified as a gap where only women seem to be the focus. This calls for more engagement of men in future studies. For some studies, innovations, including use of technology, for example use of text messages by community care workers (mHealth) to reach communities, 39 demonstrate how technology can be utilised to access health.
Access to services remains crucial for any prevention programme to be a success; therefore, free and affordable services that can improve uptake of services are employed 41 ; however, considering contexts, the affordability of such interventions across countries and sustainability of such an approach need to be further explored.

Health system interventions
Health system-related interventions included among others the importance of leaders in the health system to pave the direction for implementers; hence, leadership buy-in 27 to effect change in the use of quality-improvement model for improvement is proposed for the implementation to take place. However, models on leadership engagement need to be explored for countries to maximise benefits from it.
The reviews highlighted the importance of using reliable data systems with the health workers as implementers and adopting an approach that addresses health system improvement 25,26,27,28 as one of the strategies, for example the use of quality-improvement approaches towards improvement that promotes health system strengthening. WHO, in its framework of six building blocks, highlighted information as one of the health system-building blocks and the importance of monitoring health system performance of programmes for progress as well as impact. 23,42 Strengthening research capacity among SSA countries is seen as vital in improving implementation. This included capacity building on implementation science research targeting health workforce, especially in resource limited countries. 4,27,43,44,45 By doing so, it is believed that low-resource countries can better understand implementation science as it relates to answering critical research questions in their context. Figure 1 represents the model to summarise identified key categories.

Discussion
Our review on mapping strategies and interventions to bridge the gap in the implementation of PMTCT of HIV in the SSA countries had found articles on strategies and promising approaches used while identifying areas for future research. Based on this review, majority of papers are secondary papers (n = 9), reporting on systematic reviews and lack primary researches reported on this area. Papers also reported on barriers to implementation and enablers thereof with limited studies reporting on strategies for closing the implementation gap. It was common that for a strategy to be effective, it needed to be informed by identified barriers to implementation. 34 Evidence regarding particular strategies mostly relates to the PMTCT programme performance through data indicators monitoring of the PMTC cascade. Previous evidence had mainly focused on monitoring performance for PMTCT indicators through the PMTCT cascade. This was used to measure programme implementation, and identified gaps in the PMTCT programme coverage which identified strategies that included using quality-improvement approaches in public health care settings that focus on obtaining and building will from leadership, ideas for changes, monitoring data as well as using platforms for shared learning which was common across studies. 2,25,26,27,32,48 While task shifting emerged as one of the key solutions to bridge policy implementation gaps, and was seen as a strategy to improve healthcare coverage as well as address human resources challenges which were common across the SSA countries, inadequate supervision and poor role clarification remain a challenge. 8,49 Majority of papers report on health worker interventions including health system intervention, 22,25,26,27 with the majority reporting on the importance of engaging implementers for any implementation gap to be closed 26,27,31,39,43,44 which was found to be crucial, especially in low-resource countries.
While the strategies were offered by the SSA countries, they lack evaluations to determine the effectiveness of those identified strategies. 44 The lack of evaluation of implementation strategies hinders their assessment for effectiveness. Interventions reported including free service delivery 41 may require further assessment for sustainability of such an approach in a given low-resource country; however, the majority of SSA countries were offering free maternity services.
With countries expected to eliminate MTCT of HIV, demand for countries to speed up implementation and package interventions and strategies that are effective in closing the implementation gap remain crucial.

Strengths and limitations of this study
The review was limited to studies published in English, as it is the commonly used language for communication in the majority of SSA countries. The review was limited to articles published from 2001 to August 2016, and publications prior to this year were excluded for relevancy of the research topic as well as for reasons related to PMTCT not fully being implemented in SSA countries before 2001. The review focused on articles published in SSA countries, due to comparable settings and similar resources available.
Our review focused on the strategies and interventions for PMTCT of HIV programme to close the gap in implementation, and therefore excluded the broader aspect of other programmes that may offer strategies to close the gap in implementation; however, this review can guide future research so that a broader evidence of effective strategies used in health and other prevention programmes can be mapped.

Conclusions and recommendations
Prevention of MTCT of HIV remains a growing global public health priority, more so in the highly HIV-burdened SSA countries. This review revealed that there is no one size fits all approach in closing the implementation gap for priority prevention programmes such as PMTCT of HIV in countries with low resources. There is a need for a combination of multifaceted approaches that consider contextual settings, leadership involvement, shared learning forums while considering resources towards closing the implementation gap.
Packaging of strategies that have proven to work for scale-up to similar settings is needed; however, evaluation of such interventions and strategies for effectiveness and efficiency is of vital importance. The Global Plan vision (2011-2015), of no child shall be born with HIV and keeping mothers alive as well as eliminating MTCT of HIV until it does not constitute a public health concern, as well as achievement of universal 90-90-90 strategies require unusual business approaches as well as the engagement with researchers, policymakers, implementers and communities to prioritise implementation in the policy development phase, considering various contextual settings.