Great strides have been made in the prevention of mother-to-child transmission of HIV (PMTCT), but much remains to be done. An estimated 390,000 children worldwide were newly infected with HIV in 2010, over 86% of them through mother-to-child transmission . Mothers suffer as well: HIV has become a leading contributor to maternal mortality in sub-Saharan Africa , with an estimated 42,000 to 60,000 pregnant women worldwide dying because of HIV in 2009 . UNAIDS has developed a Global Plan to virtually eliminate new HIV infections among children and sharply reduce the number of AIDS-related maternal deaths by 2015 . The four-pronged approach involves:
preventing HIV infection among women of childbearing age;
meeting the needs of women living with HIV for family planning and birth spacing;
ensuring pregnant women’s access to HIV testing and counseling and also to antiretrovirals (ARVs) to prevent HIV transmission from mothers to infants; and
providing appropriate HIV care, treatment, and support for women and children living with HIV and their families.
Integrating PMTCT into maternal, newborn, child health, and reproductive health services has proven to be an effective strategy to reach HIV-infected mothers and their children [4, 5]. In resource-limited settings, HIV counseling and testing conducted as part of routine antenatal care (ANC) has become the main gateway to HIV prevention, treatment, care, and support services for women and children .
Zambia—where the prevalence of HIV among women of childbearing age was 16% in 2007 —has adopted this approach of integration to help reduce the spread of HIV. Like many countries with high HIV prevalence, Zambia has adopted a provider-initiated HIV testing and counseling model. New ANC clients are informed about PMTCT during group pre-test counseling. Unless a client opts out, providers then perform a rapid HIV test that produces results within one hour. Individual post-test counseling is offered as part of the standard package of ANC and delivery services . This approach has been instrumental in increasing the uptake of HIV testing among pregnant women globally . It has also contributed to high rates of HIV testing in Zambia, where 94% of pregnant women receive ANC services , and more than 95% of ANC clients accept the offer of HIV testing [8, 9]. Among pregnant women who received ANC in 2010 and 2011, 98.9% were tested for HIV and received the results; 12.3% of them were found to have HIV . The absolute number of HIV-positive women giving birth in Zambia has been slowly rising over the past decade and was estimated at about 97,000 in 2011 .
Identifying pregnant women who are infected with HIV is only the first step in PMTCT. The diagnosis must be followed by appropriate prophylaxis and treatment for mother and child. Zambian national guidelines follow recommendations issued by the World Health Organization (WHO) in 2010 . These require testing pregnant women to determine whether their CD4 count is less than 350 mm3. If so, they are eligible for lifelong antiretroviral therapy (ART). If not, they are given a short course of ARV prophylaxis beginning in the second trimester, along with postpartum prophylaxis for the infant, to prevent vertical transmission. Zambia is planning to adopt new WHO guidelines issued in 2012  that call for lifelong ART for all pregnant women with HIV, regardless of their viral load, but has not yet implemented them.
For many years, prophylaxis lagged behind HIV testing in Zambia. For example, a study of 60 primary health centers in rural and urban areas of Zambia in 2007–2008 found that only 17% of pregnant women diagnosed with HIV underwent CD4 screening, and there was further attrition before eligible women were given ART; lack of equipment to perform CD4 counts contributed to the low numbers . The situation was better in the capital city of Lusaka, where 79% of pregnant women diagnosed with HIV underwent CD4 screening from 2007 to 2010 . Nationwide, coverage has expanded rapidly in the past few years. In 2010, 80% of pregnant women with HIV in Zambia received some form of ARV prophylaxis to prevent transmission to the baby and 60.5% were assessed for ART eligibility through clinical staging or CD4 testing .
Improving the quality and the delivery of HIV prevention, care, and treatment services for women and children is an essential part of WHO’s PMTCT strategic vision 2010–2015 . In Zambia, improvements in PMTCT service delivery have the potential to increase the number of women receiving ART and reduce the number of infants born with HIV [9, 13, 14].
These lessons are important for all providers of ANC services in Zambia, including the military-run health system. The Zambia Defence Force (ZDF) operates a network of 54 hospitals and clinics that serve military personnel, their families, and surrounding civilian communities; civilians make up 80% of all clients . PMTCT is among the prevention strategies promoted by the ZDF’s HIV and AIDS Strategic Plan for 2009–2014.
The ZDF has been steadily expanding HIV-related services since 1993 , and more recently it has recognized the need to improve the quality as well as quantity of these services . In 2006, the ZDF began introducing Jhpiego’s Standards-Based Management and Recognition (SBM-R®) approach at some facilities to improve the quality of HIV-related services. SBM-R uses a set of detailed standards to guide essential tasks performed by health care workers and to measure progress in service delivery . A team of managers and health workers use SBM-R tools to identify and analyze weaknesses in service provision at their own facility and to develop an action plan to address them. Team members try to find solutions that rely on existing personnel and resources and that they can implement themselves, for example, coaching workers on specific tasks or posting job aids in consultation rooms. If necessary, however, the team may seek outside support for the action plan, for example, requesting additional staff or equipment from higher-level managers. In Zambia, the ZDF, with technical assistance from Jhpiego, provided training, supportive supervision, and on-site assistance to help staff teams analyze and address performance gaps and improve the quality of care.
Rawlins and colleagues found that the SBM-R approach improved the performance of reproductive, maternal, and child health services in Malawi . However, there are no evaluations of the effectiveness of SBM-R interventions for ANC and PMTCT services, nor has there been an assessment of the suitability of the approach for military health systems. The purpose of this study is to evaluate the effectiveness of the SBM-R approach in improving the quality of PMTCT services at ZDF facilities.