Facility-Level Factors Affecting Implementation of the Option B+ Protocol for Prevention of Mother-to-Child Transmission of HIV (PMTCT) in Kilimanjaro, Tanzania

Background: In 2013, Tanzania adopted the Option B+ protocol for prevention of mother-to-child-transmission (PMTCT) of HIV, whereby all HIV-positive pregnant women initiate lifetime antiretroviral therapy (ART). Option B+ holds great promise for improving women’s health and moving towards an “AIDS-free generation”. This study aimed to evaluate the implementation of Option B+ in selected sites in Kilimanjaro region of Tanzania using the Consolidated Framework for Implementation Research (CFIR). Methods: Data were obtained through semi-structured observations, review of clinic records, and key informant interviews (KIIs) with healthcare providers across the PMTCT care cascade. 35 hours of observation and 30 KIIs were conducted at three healthcare facilities from May 2017 to July 2017. Findings: The data revealed key themes in relation to CFIR domains. Considering the intervention characteristics, the protocol was adaptable as it was observed in three healthcare facilities with different staffing and flows of care. Considering the outer setting, providers noted that stigma and lack of partner involvement were key patient-level factors hampered implementation. Interconnectedness of facilities helping implementation, but poor referral systems existed. The maladies of the underlying health system hindered optimal implementation. Considering the individual (provider) characteristics, knowledge about the protocol varied depending on training and level of experience. There was consensus that Option B+ was effective in preventing vertical HIV transmission. However, considering the process of implementation, fidelity of implementation varied across clinics and over time, determined by providers present, clinic set-up, time of day and patient volume. As observed, the burden of record keeping appeared to hamper focused provider-patient interactions. Discussion: Future success in implementation of the Option B+ protocol in Tanzania requires additional training of providers on the guidelines, including counseling and patient-centered care. Community education focusing on stigma reduction and uptake of HIV testing among men will provide a more supportive implementation context. Implementation activities extending beyond the clinical setting, including home-based care, are needed. Electronic medical records may decrease the burden of redundant documentation, help track women lost to follow-up at the clinic level and improve the quality of care.