All ETDs from UAB

Advisory Committee Chair

Janet M Turan

Advisory Committee Members

Craig R Cohen

Jeffrey Engler

Nir Menachemi

Stephen T Mennemeyer

Document Type

Dissertation

Date of Award

2017

Degree Name by School

Doctor of Public Health (DrPH) School of Public Health

Abstract

It is estimated that a third of all mother-to-child transmission (MTCT) of HIV occurs in women with incident HIV infection during pregnancy, potentially contributing to over 37,000 pediatric HIV infections globally and 4,300 infections in Kenya on an annual basis. Since most pregnant women with acute HIV infection test negative for HIV during routine early-pregnancy antenatal testing, they may not receive access to life-saving antiretroviral therapy (ART) for their own sake, as well as to prevent perinatal HIV transmission. A comprehensive strategy to eliminate MTCT will require identifying and addressing incident HIV infection. International recommendations suggest that pregnant women in generalized epidemic settings be offered retesting three months after an initial negative HIV test early in pregnancy. The Kenyan Ministry of Health has officially adopted these guidelines, but little is known about the implementation successes and challenges. This dissertation is comprised of three manuscripts examining the implementation of repeat HIV testing during pregnancy in Kenya using primary and secondary data collected from October 2014 to May 2015. The aims of this dissertation are to use qualitative and quantitative research approaches to (A) determine the current rate of antenatal retesting at a large district hospital in southwestern Kenya, as well as identify factors associated with retesting and estimate the incidence of HIV during pregnancy, through retrospective analysis of antenatal clinic records; (B) explore the barriers and enablers to retesting at four socioecological levels (client, provider, facility, and health system) using the Ferlie and Shortell Framework for Change through in-depth interviews with health care providers and managers; and (C) model the cost, health impact, and cost-effectiveness of expanded repeat HIV testing during pregnancy in the Kenyan setting, compared to initial HIV testing alone. Findings suggest that HIV incidence during pregnancy among women in southwestern Kenya remains high. While retesting rates have increased since guideline dissemination, implementation efforts appear to have lagged in some sub-groups, in particular leaving high-risk young, unmarried women less likely to get retested. Although some barriers to repeat HIV testing of pregnant women exist, health care providers and program managers generally see implementation as important, feasible, and acceptable. Implementation of repeat HIV testing in high HIV-prevalence areas of Kenya is cost-effective and likely to avert substantial new pediatric infections, but will require a multi-sector commitment to capitalize on community strengths.

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