Reducing new HIV infections is a global health priority, especially in sub-Saharan Africa, where 70% of new HIV infections and 75% of vertical infections occur. Due to shortages in health workers and other resources, significant coverage gaps exist in initial HIV testing of pregnant women at antenatal care (ANC) and referrals of those who are HIV-positive for prevention of mother-to-child transmission (PMTCT) and treatment. Furthermore, almost no attention is given to the prevention needs of HIV-negative pregnant women at ANC. As a result, researchers and policy makers have called for innovative approaches to reconceptualize the ANC- HIV-PMTCT care continuums. The proposed R21 will be the first adaptation of the CenteringPregnancy (CP) group ANC care model in low-resource, high HIV prevalence settings. The shift to group care is an innovative paradigm that makes more efficient use of scare health practitioner time and improves quality of care by incorporating essential HIV-related information and services into ANC for all women, regardless of HIV status. In CP-Africa, a group of 12 mixed status (HIV positive and negative) women with similar due dates meet with the same trained practitioner at every ANC visit. Self and practitioner assessments and practitioner-initiated linkages to others services (e.g., PMTCT) occur in the first 30 minutes. This is followed by 90 minutes of education and skill-building to promote awareness of HIV testing, prevention, and treatment options and build self-efficacy leading to behavioral changes and increased health system use. Continuity of care will strengthen linkages to HIV-related and other services as women forge a collaborative relationship with a specific practitioner. Couples testing is promoted by inviting men to an HIV session followed by a testing opportunity. This R21 will be used to complete essential developmental work that will enable us to bring this paradigm- changing model to sub-Saharan Africa and allow us to move toward testing the efficacy of CP-Africa on a large scale. Guided by principles of community-based participatory research, we will develop and pilot CP-Africa in Malawi and Tanzania, countries with different HIV prevalence (11% vs. 6%), HIV testing rates, and PMTCT coverage. ANC sessions and activities, procedures to schedule practitioner time, meeting space, form groups and facilitate follow-up on individual women's HIV, PMTCT, and other needed services will be developed collaboratively with stakeholders. Outcome measures new to sub-Saharan Africa will be validated by cognitive interviewing. We will then pilot the entire CP-Africa package at 4 sites with 192 women randomized into CP- Africa or individualized care;obtain baseline, late pregnancy and 8 week post birth outcome data;and conduct full process evaluations of the implementation process including direct observation of sessions and qualitative assessments by women and providers. Data from this study will be collated and used to refine the CP-Africa package to prepare for a clinical trial. If CP-Africa can be successfully adapted in two African countries, this will enhance the likelihood of success in other low-resource settings.
Antenatal care (ANC) is an ideal venue for HIV education and prevention of mother-to-child transmission (PMTCT), but severe health worker and resource shortages in sub-Saharan Africa limit ANC's capacity to meet these goals. The proposed research will adapt and pilot an innovative, evidence-based model of group ANC that restructures provider time, allowing resource-limited health facilities to offer high quality ANC inclusive of HIV prevention and PMTCT. This project will be conducted in two high HIV prevalence African countries, Malawi and Tanzania, and will provide the necessary data for a larger study which may provide a model for other high prevalence, low resource countries.