While HIV programs provide lifesaving care and treatment to millions of people in lower-income countries, there have been concerns that as these programs expand, they divert investments from other health priorities such as maternal health. Researchers at Columbia University's Mailman School of Public Health assessed the effect of HIV programs supported by the President's Emergency Plan for AIDS Relief (PEPFAR) on access to maternal health care in sub-Saharan Africa for women who are not infected with HIV. The findings show that, in fact, PEPFAR-funded, HIV-related projects were linked to more deliveries in health facilities. Encouraging more women to deliver in a health facility is essential to reduce maternal and newborn mortality globally. The study is published in the July edition of the journal Health Affairs, a theme issue about the impact of PEPFAR.
Until this research, there had been limited statistical data about the interactions between HIV programs and existing health systems in low-income countries. The study by the Columbia investigators is among the first to use longitudinal health system data to examine whether HIV services promote or detract from maternal health services provided in the same facilities. Using data from 257 health facilities in eight African countries supported by ICAP-Columbia University through PEPFAR funding, the research looked at the scope and intensity of HIV services and their impact on the provision of prenatal and delivery care in the same facilities. HIV is a leading cause of death in sub-Saharan Africa, but is only one of several important health priorities for the region. Half of the world's maternal deaths also occur here.
The 257 health facilities each provided antiretroviral therapy to an average of 330 patients, initial prenatal care to 224 women who were not infected with HIV, and delivery services to slightly under 200 uninfected women each quarter from 2007 to 2011. Controlling for other variables, the researchers found that having more patients on antiretroviral treatment, and more HIV-related infrastructure investments, such as on-site laboratories with HIV-specific tests at health clinics, were associated with more deliveries at these facilities by women not infected with HIV. This is likely because HIV investments supported other health services and laid the foundation for improving health system performance overall.
"There may be several possible explanations for the positive association between HIV programs and the number of deliveries in health facilities," said Margaret E. Kruk, MD, MPH, Mailman School Assistant Professor of Health Policy and Management and first author. "For example, as HIV treatment programs expand, a larger number of community members may learn about the health facility and its services. Another factor could be that HIV-infected patients enrolled in HIV programs who have favorable experiences with the facility encourage family and friends to use the facility for obstetric care." Dr. Kruk also cited the possibility that expansion of HIV services with their focus on high quality and patient-centered care may have led to facility-wide improvements in patient care. What is most notable, according to Dr. Kruk, is that there were no negative effects on the utilization of maternal health services as a result of providing HIV care at the same facility.
"Our earlier research suggests that patients are strongly influenced by the perceived quality of facility equipment. Visible upgrades—evident to all patients, not just those with HIV—may influence the decision to give birth in a health facility."
The challenge facing policy makers going forward, noted Dr. Kruk and colleagues, is how best to implement HIV services while supporting other essential health care. Additional research needs to explore how HIV programs can be actively leveraged to improve health systems and, in turn, the health of the general population.
"There are certainly lessons to be learned from PEPFAR about how to strengthen the quality of other high-priority health services, such as child and maternal healthcare, but also how to tackle new and rapidly growing threats, such as diabetes, hypertension, and other chronic, non-communicable diseases," said Dr. Kruk.