SUPPORTING THE IMPLEMENTATION OF GUIDELINES TO PREVENT MOTHER-TO-CHILD-TRANSMISSION OF HIV IN MALAWI: A QUALITATIVE DESCRIPTIVE CASE STUDY

Chifundo Colleta Zimba: Supporting the implementation of guidelines to prevent mother-to-child transmission of HIV in Malawi: A qualitative descriptive case study (Under the direction of Jennifer Leeman) The burden of human immunodeficiency virus (HIV) on women aged 15–49 years is high in Malawi (13%), resulting in HIV transmission to 12,000 children in 2011. Malawi has adopted the Option B+ guidelines which, if fully implemented, could prevent over 95% of HIV cases in children born to HIV-infected women. Because adoption of guidelines is not enough to move science into practice, the UNC Project—a partner organization to the Malawi government—provided prevention support (e.g., training and technical assistance [TA]), to 134 Malawian clinics between 2011 and 2014 to enhance implementation of the Option B+ guidelines. This qualitative, descriptive multiple-case study aimed to describe the types of prevention support the UNC Project provided to 4 clinics, how support varied across low- and high-performing clinics, and factors that may explain variations in Option B+ implementation across clinics (N=4). Data were gathered through 21 in-depth interviews with 18 key stakeholders (n=6 TA providers and n=12 care providers). Observation supplemented data from in-depth-interviews. Directed content, thematic, and cross-case analyses were used to analyze data. The study found that the UNC Project used the following prevention support strategies: off-site trainings of the service providers; ongoing, onsite TA that employed collaborative and audit and feedback approaches; tools such as standard operating procedures (SOPs); and resources such as HIV testing kits. Variations occurred in TA dose (i.e., time TA providers spent on guidelines activities in the clinic and community) and on TA focus (i.e., the unit where TA providers spent more hours). All four clinics reported full implementation of most of the Option B+ guideline core components. Implementation gaps were found on community mobilization, documentation, and components done during the post-delivery period. Staffing and transportation emerged as the most salient contextual factors influencing TA delivery while size of the clinic staff, service space/infrastructure, stocks of the HIV testing kits, and magnitude of the served population explained differences in guideline implementation between low- and high-performing clinics. Results of this study can help advance understanding of the way prevention support enhances implementation of new evidence-based interventions and contextual factors that may need to be addressed.Doctor of Philosoph