International Journal of Gynecology and Obstetrics 130 (2015) S70–S72

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International Journal of Gynecology and Obstetrics

journal homepage: www.elsevier.com/locate/ijgo

LESSONS FROM THE FIELD

Lessons learned from integrating simultaneous triple point-of-care

screening for syphilis, hepatitis B, and HIV in prenatal services through
rural outreach teams in Guatemala
Adriana Smith a, Meritxell Sabidó b,c,⁎, Elsy Camey a, Anabelle Batres d, Jordi Casabona c,e,f
a
Fundació Sida i Societat, Escuintla, Guatemala
b
TransLab, Department of Medical Sciences, Universitat de Girona, Girona, Catalonia, Spain
c
Fundació Sida i Societat, Barcelona, Catalonia, Spain
d
Escuintla Health Department, Guatemalan Ministry of Health and Social Assistance, Escuintla, Guatemala
e
Center for Epidemiological Studies on HIV/AIDS and STI of Catalonia (CEEISCAT), Institut Català d´Oncologia/Health Department, Generalitat de Catalunya, Badalona, Catalonia, Spain
f
CIBER Epidemiología y Salud Pública (CIBERESP), Spain

a r t i c l e i n f o a b s t r a c t

Keywords: Mother-to-child-transmission of HIV, syphilis, and hepatitis B virus (HBV) remains a challenge in Guatemala,
Hepatitis B especially in rural regions. A triple antenatal screening program for these infections using point-of-care (POC)
HIV testing offered through outreach teams was implemented in the municipality of Puerto de San José. One year
Point-of-care testing following program implementation, antenatal care coverage increased to 99.6% (32.5% increase, P b 0.001),
Pregnancy
testing uptake increased to 50.3% for HIV and syphilis (143.9% (P b 0.001) and 1.3% (P = 0.89) increase,
Syphilis
respectively), and HBV testing increased from 0 to 42.2%. Lessons learned showed that, despite the expansion
of triple antenatal POC screening in rural Guatemala, a shortage of healthcare workers and poor supply chain
management limited screening uptake. Moreover, training is essential to help health workers overcome their
fear of communicating positive results and improve partner notification. Engagement of community health
workers was essential to build local capacity and facilitate community acceptance.
© 2015 World Health Organization; licensee Elsevier. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Background 2. Local settings

In Guatemala, antenatal screening is offered in public health facilities Guatemala has an HIV prevalence of 0.71% among pregnant women
centralized in larger towns. Thus, access to care remains limited for rural [5] and an estimated rate of MTCT of HIV of 5.1% [2]. Syphilis prevalence
communities, challenging the prevention of mother-to-child transmis- among pregnant women is estimated at 0.10%, with a congenital syph-
sion (MTCT) of HIV and other sexually transmitted infections (STIs) ilis rate of 0.03 cases per 1000 live births and 71% of syphilis-positive
[1]. Only 35% and 47% of pregnant women are tested for HIV and pregnant women receiving appropriate treatment [2]. The low syphilis
syphilis, respectively, with no testing being currently offered for hepati- prevalence and screening and treatment coverage in pregnancy indi-
tis B virus (HBV) [2]. Community screening through outreach teams can cates that Guatemala is showing progress but is yet to meet the goal
be an alternative model to expand antenatal screening for these infec- of elimination of MTCT for this infection [2]. Regarding HBV, there are
tions and reach pregnant women unware of their HIV, syphilis, or HBV no data available on its prevalence in Guatemala. In response to the
status [3]. The use of rapid tests could enhance the effectiveness of out- need for strengthening the prevention of MTCT of HIV and syphilis, in
reach screening by increasing testing uptake and the proportion of pa- 2011 the Guatemalan Ministry of Health (MOH) launched a national
tients who receive their results [4]. The aim of the present article is to plan that included the expansion of antenatal care services and
describe the key lessons learned following one year’s implementation screening for both infections [6]. Further, the MOH emphasized the
of triple point-of-care (POC) screening for HIV, syphilis, and HBV importance of HBV screening during pregnancy, although it was
through outreach teams in rural Guatemala. not included in the national plan.
The magnitude of the HIV and syphilis epidemic is particularly evi-
dent at the Escuintla Department, which has the second highest preva-
⁎ Corresponding author at: TransLab, Department of Medical Sciences, Universitat de
Girona, Plaça Sant Domènec, 3, Edifici Les Àligues, 17071 Girona, Catalonia, Spain.
lence of HIV and other STIs in Guatemala [5]. One of the main cities in
Tel.: +34 972 418 000. the Escuintla Department is Puerto de San José (PSJ), located on the
E-mail address: [email protected] (M. Sabidó). southern coast. PSJ has low literacy, poor maternal and child health

http://dx.doi.org/10.1016/j.ijgo.2015.04.009
0020-7292/© 2015 World Health Organization; licensee Elsevier. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 A. Smith et al. / International Journal of Gynecology and Obstetrics 130 (2015) S70–S72 S71

indices, intense seasonal migration, and a widespread illegal drug and 4.3. Prenatal care and testing uptake
sex trade [7]. The Fundació Sida i Societat (FSIS) is a non-profit organi-
zation that has been providing technical assistance for the prevention Before the introduction of the outreach screening program, antena-
of HIV in Guatemala since 2005. In 2012, FSIS partnered with the tal care coverage in public healthcare services in PSJ was 73.7%, increas-
National Program of Prevention and Control of HIV/AIDS and STIs and ing to 99.6% following its introduction and resulting in a significant
the local department of health to implement a triple antenatal screening increase of 32.5% (P b 0.001). Before the introduction of triple POC
program for HIV, syphilis, and HBV using POC testing offered through screening, antenatal testing in PSJ was reported at 20.6% and 49.6% for
outreach teams in PSJ. Funding to expand triple antenatal screening in HIV and syphilis, respectively, and no testing was available for HBV.
rural Guatemala was provided by Fundació Intervida and CIBER of Following its introduction, testing uptake was 50.3% for HIV and
Epidemiology and Public Health. syphilis, and 42.2% for HBV. For HIV and syphilis, this corresponded
to an increase of testing uptake of 143.9% (P b 0.001) and of 1.3%
(P = 0.87), respectively. Overall, 51.3% of pregnant women (462/901)
3. Approach were screened in health posts or by outreach teams and 48.7% at the
district healthcare center.
Triple antenatal screening using POC testing was introduced through
the existing public network of health services and outreach health 4.4. Case detection and management
teams. PSJ is equipped with a district primary healthcare center, two
health posts with fixed healthcare workers, and 22 convergence centers, Of the 901 women screened, eight tested positive for syphilis
which are community spaces utilized for gatherings and events. Three (0.89%) and three for HIV (0.33%). No cases of HBV were detected. All
mobile health outreach teams, each composed of two nurses and positive cases were identified in the health posts or by the outreach
seven health promoters, rotated between convergence centers offering teams. All syphilis cases were confirmed, treated, and their partners no-
basic primary care services. These outreach teams also coordinated with tified, although only two partners were tested. Two out of three HIV
a network of over 200 traditional midwives. Health promoters and positive cases accepted referral to the department hospital for HIV
traditional midwives identified pregnant women and referred them treatment. Although notified, none of these partners were tested.
for testing.
Nurses or nurse practitioners collected written informed consent 5. Lessons learned
and offered pre-test counseling. They also collected a single finger-
prick sample to perform HIV testing using the Determine HIV-1/2 This outreach program allowed the municipality of PSJ to expand tri-
rapid test (Abbott Laboratories, Tokyo, Japan), syphilis testing using ple POC screening for pregnant women in rural Guatemala. One of the
the SD Bioline Syphilis 3.0 (Standard Diagnostics, Kyonggi-do, Korea), key lessons learned was the importance of establishing a collaborative
and HBV testing using the Determine HBsAg tests (Alere Inc., MA, partnership with local and national authorities and early involvement
USA). Women received their results within 15 minutes and those with of community healthcare workers. Overall, this program was successful
a reactive test result were referred for confirmatory testing and treat- in increasing antenatal care coverage, considering that 99.6% of preg-
ment following national guidelines [8]. nant women presented at the healthcare services, representing an in-
crease of 32.5% from before its introduction. The promotional efforts of
traditional midwives and health promoters, coupled with delivering
4. Relevant changes screening closer to the community, might have removed barriers for
testing and contributed to the observed increase [9]. Nevertheless, ap-
4.1. Start-up process proximately half of the women that presented to the healthcare services
did not receive any of the tests, mainly owing to staff turnover and ab-
Overall, 14 healthcare workers (nurse or nurse practitioners), 21 senteeism, as well as poor supply chain management. This low testing
health promoters, and 200 traditional midwives were trained in POC coverage threatens the cost-effectiveness and sustainability of the triple
testing promotion and use, counseling, referral, stock management, screening program, especially for HBV. The low screening of pregnant
and record keeping. Healthcare workers involved in testing were addi- women for HBV might be due, in part, to logistic problems with supply
tionally trained on how to perform the tests and interpret results chain and that HBV testing is not included in national guidelines, despite
using standard operational procedures and quality assurance using pro- it being a recognized effective strategy to reduce MTCT of this infection
ficiency panels. FSIS staff performed regular field supervision visits [10]. After only one year and the low number of positive cases identified,
using checklists. All tests, reagents, and treatments were supplied it is not possible to comment on the success of the program regarding
through the MOH’s routine channels. POC triple screening was promot- the treatment and referral of cases.
ed through a campaign using radio advertisement and leaflets. Partner notification is an important step in case management to help
interrupt transmission and prevent re-infections and complications
[11]. Nurses and health promoters reported difficulties in partner noti-
4.2. Triple screening coverage and characteristics of pregnant women fication as many women feared communicating positive results to
their partners. Gender inequity and the economic vulnerability of
From May 2012 to April 2013, 1793 pregnant women sought women in Guatemala hinder their ability to make decisions regarding
antenatal care either at the district health center or health posts, or their sexual and reproductive health [12].
through mobile outreach teams. Of those, 901 (50.3%) were screened Site visits revealed that nursing staff feared delivering a positive re-
for HIV and syphilis and 756 (42.2%) for HBV owing to unavailability sult; thus, in cases of indeterminate or ambiguous results, they were
of the HBV test during the first two months. Women not tested either more likely to report these as negative. Nevertheless, a refresher train-
did not accept testing because of fear of a positive result, additional ing on post-counseling for positive results and an intensification of
waiting time, or partner disapproval, or testing was not available field visits dissuaded some of this behavior.
because of staff turnover, absenteeism, or stockouts at the district
health center. The women’s mean age was 24 ± 14.5 years and 28.3% 6. Conclusions
were 18 years or younger. The median time point in gestation
at which women were tested was 16 weeks. Only 9.2% had been The outreach program was able to expand triple POC screening for
previously tested. pregnant women in rural Guatemala. Following this pilot program,
S72 A. Smith et al. / International Journal of Gynecology and Obstetrics 130 (2015) S70–S72

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