Perceived Implementation of Guidelines to Prevent Mother-to-Child Transmission of HIV in Malawi: A Qualitative Multiple Case Study

Purpose: To describe the extent to which four rural Malawi clinics implemented the core components of the 2011 Malawian Option B+ guidelines following three years of an extensive implementation support program.

Methods: This study used a descriptive multiple case-study design. N=4 clinics were purposefully sampled from a total population of 134 health facilities. Of the 4, n=2 fell into the highest while n=2 into the lowest quartile of the proportion of eligible women who were tested for HIV in Fiscal Year 2012-2013. In-depth interviews were done with 18 informants who were actively involved in either implementing (n=12) or providing support for implementation (e.g., technical assistance, tools; n=6) of the guidelines at the study clinics. To assess perceived implementation of the guidelines at clinic level, all informants were asked to what extent the study clinics were carrying out each of the core components of the Option B+ guidelines. Responses were ranked from 0 to 3, with 0 assigned when the interviewee reported that the component was never implemented and 3 when always implemented as specified by the guidelines. Each clinic’s responses were then averaged for each item to create a final score. Clinics were coded as HP-1, HP-2, LP-1 and LP-2.

Results: All four clinics reported full implementation of most of the core components. Self-rating of implementation ranged from 2.3 to 2.8 on a scale of 3.0. An outstanding performance was reported to have occurred at HP-2 clinic with an overall score of 2.8 while both LP clinics reported scores of 2.3. A critical assessment of each of the core components across all the four study sites showed that all but HP-2 clinic minimally conducted community sensitization and mobilization activities; both LP clinics failed to fully identify and ascertain HIV status of the HIV exposed children at 6 weeks, 12, and 24 months; and all but the LP-1 clinic reported documentation problems.

Conclusion: After three years of implementation of the Option B+ guidelines with an aid of extensive supporting strategies, all four Malawian rural clinics reported full implementation of most of the core components of the implemented guidelines. On a scale of 0 to 3, self-rating of implementation ranged from 2.3 to 2.8. Documentation of rendered activities; failure to fully sensitize and mobilize the served communities; and failure to identify and ascertain HIV status of the HIV exposed children are gaps that exist in implementation of the Option B+ guidelines. If communities are not well informed, fewer women in need of ART will benefit from the implemented guidelines which could lead to many babies contacting HIV infection from their mothers. Failure to properly document the rendered activities and identify and test the HIV-exposed children as per guidelines hindered clinics’ ability to assess the impact of the Option B+ guidelines on maternal transmission of HIV. Further research is required to test implementation support strategies that may enhance community awareness, quality documentation and early identification of HIV exposed children in order to prevent mother-to-child transmission of HIV in Malawi.