In response to PAR-10-038, we propose to test whether adapting an established HIV/AIDS program support platform to strengthen maternal and newborn health (MNH) services will increase uptake of these services and thus improve outcomes for both HIV-negative and HIV-positive women and their newborns. One of NIAID's key strategic priorities is to reduce health disparities and improve health by using translational research. Tanzania, the largest country in East Africa, has an HIV prevalence of 5.7% and some of the highest maternal and neonatal mortality rates in the world. With the support of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), Tanzania has made remarkable progress in providing HIV services, averting 7,500 newborn HIV infections in 2009 alone. In contrast, expanding uptake of basic maternal and newborn health (MNH) services needed to reduce maternal and newborn mortality has been less successful. Fewer than half of Tanzania's women and newborns utilize high-quality MNH services, despite the existence of well-defined policies and guidelines. Our preliminary data suggest that low service utilization may be due to poor quality of services. Poor quality of services in turn results in poor health outcomes. To succeed in the same weak health systems, HIV programs have pioneered an innovative approach to upgrade infrastructure, provide training and quality assurance, and work with local communities. Could this three-pronged health system support strategy originally developed for HIV programs be expanded to improve the quality and uptake of MNH services? Despite its clinical and public health relevance, there are no randomized studies to answer this question. This study will use rigorous research methods to define effective strategies for scaling evidence- based health services in clinical and public health settings. We propose to undertake a cluster-randomized study to test the hypothesis that adapting HIV program strategies to strengthen MNH services (MNH+) will increase quality and utilization of essential MNH and HIV services among Tanzanian women. The study will be done jointly with the Tanzania Ministry of Health, Ifakara Health Institute, the International Center for AIDS Care and Treatment Programs (ICAP), the Averting Maternal Death and Disability Program. Twelve health centers in Pwani Region (eastern Tanzania) will be paired on baseline characteristics and randomly allocated to receive support to improve the quality and reach of MNH services or join the control group. Population-level utilization of antenatal, delivery, postnatal, PMTCT and HIV care will be assessed using population- representative surveys of 3000 women living within the catchments of intervention and control health centers. Improvements in quality and extent of implementation of the intervention will be tracked using detailed facility data, using ICAP's monitoring frameworks, and structured clinical observation. Understanding whether the HIV experience can be leveraged for maternal and newborn health care can assist in the translation of evidence from bedside to the community (T2 translation) to save maternal and newborn lives in low-income countries.
There are massive global disparities in maternal, newborn, and HIV/AIDS mortality, with sub-Saharan Africa most severely affected. In the past eight years the President's Emergency Plan for AIDS Relief (PEPFAR), an HIV prevention and treatment program, has successfully overcome structural health system barriers in low- income countries to provide HIV testing, care, and treatment for millions of people. This cluster-randomized implementation research study will test whether adapting and expanding PEPFAR's health system support strategy to strengthen maternal and newborn health services can improve the utilization, equity, and quality of maternal and newborn health services and HIV services in eastern Tanzania-an area with high HIV prevalence and high rates of maternal and newborn mortality.
