Integrating HIV and Maternal, Neonatal and Child Health Services in Rural Malawi: An Evaluation of the Implementation Processes and Challenges

Introduction: Introducing Option B+ in Malawi increased anti-retroviral therapy coverage among pregnant and breastfeeding women 3 fold. The Promoting Retention among Infants and Mothers Effectively (PRIME) study integrated care of Maternal, Neonatal and Child Health services through a mother-infant pair (MIP) clinic. This article evaluates the implementation processes and challenges health care workers' experienced in implementing these MIP clinics. Methods: Between May 2013 and August 2016, 20 health facilities implemented MIP clinics. Health care workers' performance implementing MIP clinics was assessed through a mentorship score from 0 to 5 and supplemented with qualitative data from mentorship reports. Visit alignment of participants' appointment and attendance dates with MIP clinic dates were calculated and summarized by overall proportions among all patient visits. Results: The average mentorship score was 3.8, improving from 3.0 to 4.2 from quarter one 2015 to quarter one 2016. Proportions of maternal and infant appointment dates that aligned with MIP clinic dates were 47.0% and 5.9%, with greatest improvement between 2013 and 2015. Proportions of maternal and infant attendance dates that aligned with MIP clinic dates were 41.7% and 51.2% and improved over time. Discussion: Despite improvement in staff mentorship scores, many MIPs were not exposed to integrated HIV and Maternal, Neonatal and Child Health services offered through MIP clinics primarily because of clinic scheduling challenges. To improve utilization of integrated MIP clinics, careful design of a delivery approach is needed that is acceptable to clinic staff, addresses local realities, and includes appropriate investment and oversight.