Please select the eligibility criteria that correspond to the clinical trial below.
Title: Continuous Quality Improvement Interventions to Improve Long Term Outcomes of Antiretroviral Therapy in Women Initiated on Therapy During Pregnancy or Breastfeeding in the Democratic Republic of Congo
Brief Summary: Despite the rapid adoption of the World Health Organization's 2013 guidelines, many children continue to be infected with HIV perinatally because of sub-optimal adherence to the continuum of HIV care in maternal and child health clinics (MCH). To achieve the UNAIDS goal eliminating mother-to-child HIV transmission, multiple, adaptive interventions will need to be implemented to improve adherence to the HIV continuum. The aim of this open label, parallel groups, randomized controlled trial is to evaluate the effectiveness of Continuous Quality Improvement (CQI) interventions implemented at facility and health district level to improve retention in care and virological suppression through 24 months postpartum among pregnant and breastfeeding women receiving ART in MCH clinics in Kinshasa, Democratic Republic of Congo. Prior to randomization, the current monitoring and evaluation system will be strengthen to enable collection of high quality individual patient-level data necessary for the timely production of indicators and monitoring of program outcomes to inform CQI interventions. Following randomization, in health districts randomized to CQI, quality improvement (QI) teams will be established at the district level and at MCH clinics level. For 18 months, QI teams will be brought together quarterly to identified key bottlenecks in the care delivery system using data from the monitoring system, develop an action plan to address those bottlenecks, and implement the action plan at the level of their district or clinics. If proven to be effective, CQI as designed here, could be scaled up rapidly in DRC and other resource-limited settings to accelerate progress towards the goal of an AIDS free generation.


Options:
A: Key Inclusion Criteria:

* Ability to understand and sign a written informed consent form, which must be obtained prior to initiation of study procedures
* Currently receiving antiretroviral therapy consisting of E/C/F/TDF, EFV/FTC/TDF, RTV+ATV+FTC/TDF, or COBI+ATV+FTC/TDF for ≥ 6 consecutive months preceding the final visit in their earlier study
* Completion of the Week 144 visit in studies GS-US-236-0102, GS-US-236-0103, GS-US-216-0114, or completion of the Week 96 visit in study GS-US-264-0110 (only participants on an EFV-based regimen), or completion of studies GS-US-236-0104, GS-US-216-0105
* Plasma human immunodeficiency virus type 1-ribonucleic acid (HIV-1 RNA) concentrations at undetectable levels for at least 6 consecutive months prior to the screening visit and have HIV RNA \< 50 copies/mL at the screening visit
* Normal echocardiograph (ECG)
* Estimated glomerular filtration rate (GFR) ≥ 50 mL/min according to the Cockcroft-Gault formula for creatinine clearance
* Hepatic transaminases (aspartate aminotransferase \[AST\] and alanine aminotransferase \[ALT\]) ≤ 5 × upper limit of the normal range (ULN)
* Direct bilirubin ≤ 1.5 x ULN
* Adequate hematologic function
* Serum amylase ≤ 5 × ULN
* Females of childbearing potential must agree to utilize highly effective contraception methods or be non-heterosexually active or practice sexual abstinence from screening throughout the duration of study treatment and for 12 weeks following the last dose of study drug if receiving EFV/FTC/TDF regimen, and 30 days for those assigned to all other regimens.
* Female participants who utilize hormonal contraceptive as one of their birth control methods must have used the same method for at least three months prior to study dosing
* Female participants who have stopped menstruating for ≥ 12 months but do not have documentation of ovarian hormonal failure must have a serum follicle stimulating hormone (FSH) level at screening within the post-menopausal range based on the Central Laboratory reference range

Key Exclusion Criteria:

* A new acquired immunodeficiency syndrome (AIDS)-defining condition diagnosed within the 30 days prior to screening
* Hepatitis B surface antigen position
* Hepatitis C antibody positive
* Participants experiencing decompensated cirrhosis
* Females who are breastfeeding
* Positive serum pregnancy test
* Have an implanted defibrillator or pacemaker
* Current alcohol or substance use judged by the Investigator to potentially interfere with subject study compliance
* History of malignancy within the past 5 years or ongoing malignancy other than cutaneous Kaposi's sarcoma, basal cell carcinoma, or resected, noninvasive cutaneous squamous carcinoma
* Active, serious infections (other than HIV-1 infection) requiring parenteral antibiotic or antifungal therapy within 30 days prior to baseline
* Any other clinical condition or prior therapy that, in the opinion of the Investigator, would make the subject unsuitable for the study or unable to comply with dosing requirements
* Participation in any other clinical trial without prior approval from the sponsor is prohibited while participating in this trial
* Participants receiving ongoing therapy with drugs not to be used with elvitegravir (EVG), COBI, FTC, TDF, ATV, RTV, EFV, and TAF or participants with any known allergies to the excipients of E/C/F/TDF, E/C/F/TAF, EFV/FTC/TDF, ATV, COBI, RTV, or FTC/TDF

Note: Other protocol defined Inclusion/Exclusion criteria may apply.
B: Note: As of 08/10/07, the arm assignments for current and new participants have changed. Please see the above description for this trial for more information.

Inclusion Criteria for Mothers:

* 18 years of age or older
* HIV infected
* In third trimester of pregnancy, or at most 3 days post-delivery
* If baby is not yet born, planning to deliver at a facility where the study is being conducted
* Plan to breastfeed

Exclusion Criteria for Mothers:

* Complications with this pregnancy
* Serious medical condition that would interfere with the study (e.g., that would prevent breastfeeding or adherence to the follow-up schedule), as judged by the on-site clinician

Inclusion Criteria for Infants:

* Born to an HIV infected mother who is eligible for the study
* Weighed at least 2000 grams (4.4 lbs) at birth
* Blood sample obtained from the infant for HIV-1 DNA PCR, CBC with differential, and ALT
* Infants in a multiple birth are eligible only if both/all infants are eligible for the study and assigned to the same study group
* Able to breastfeed (e.g., mother and infant alive with no condition apparent that would prevent breastfeeding)

Exclusion Criteria for Infants:

* HIV DNA PCR positive at birth
* ALT of Grade 2 or higher at birth
* Hemoglobin, absolute neutrophil count, or platelet count of Grade 3 or higher at birth
* Skin rash of Grade 2B (urticaria), Grade 3, or above
* Confirmed or suspected clinical hepatitis
* Serious illness or condition that would interfere with compliance with study procedures
C: Inclusion Criteria:

* Pregnant or breastfeeding women receiving care in one of the participating maternal and child health clinics
* HIV-exposed infants born from participating mothers

Exclusion Criteria:

* refuse to participate
D: Antepartum Component Inclusion Criteria:

* Confirmed HIV-1 infection, defined as documented positive results from two samples collected at different time points prior to study entry. More information on this criterion can be found in the protocol.
* Currently pregnant and greater than or equal to 14 weeks gestation based on clinical or other obstetrical measurements
* CD4 count greater than or equal to 350 cells/mm\^3, or greater than or equal to the country-specific threshold for initiation of treatment (if that threshold is greater than 350 cells/mm\^3), on a specimen obtained within 30 days prior to study entry
* Results of HBV screening (HBsAg testing) available from specimen obtained within 30 days prior to study entry
* The following laboratory values from a specimen obtained within 30 days prior to study entry:

  1. Hemoglobin greater than or equal to 7.5 g/dL
  2. White blood cell count (WBC) greater than or equal to 1,500 cells/mm\^3
  3. Absolute neutrophil count (ANC) greater than or equal to 750 cells/mm\^3
  4. Platelets greater than or equal to 50,000 cells/mm\^3
  5. Alanine aminotransferase (ALT) less than or equal to 2.5 times the upper limit of normal (ULN)
  6. Estimated creatinine clearance of greater than or equal to 60 mL/min using the Cockroft-Gault equation for women
* Plans to deliver in the study-affiliated clinic or hospital
* Has no plans to move outside of the study site area during the 24 months following delivery
* Age of legal majority for the respective country and willing and able to provide written informed consent

Antepartum Component Exclusion Criteria:

* Participation in PROMISE for a prior pregnancy
* Ingestion of any antiretroviral (ARV) regimen with three or more drugs (regardless of duration) or more than 30 days of a single or dual ARV regimen during current pregnancy, according to self report or available medical records
* Requires triple ARV therapy (HAART) for own health based on local standard guidelines
* World Health Organization (WHO) stage 4 disease
* Prior receipt of HAART for maternal treatment indications (e.g., CD4 less than 350 cells/mm\^3 or clinical indications); however, could have received ARVs for the sole purpose of prevention of mother-to-child transmission (PMTCT) in previous pregnancies (prior PMTCT regimens could have included a triple ARV regimen, ZDV, 3TC-ZDV, and/or sdNVP for PMTCT, as well as use of a short dual nucleoside reverse transcriptase inhibitor \[NRTI\] "tail" to reduce risk of NVP resistance.)
* In labor - at onset or beyond (may be eligible for the Late Presenter registration)
* Clinically significant illness or condition requiring systemic treatment and/or hospitalization within 30 days prior to study entry
* Current or history of tuberculosis (TB) disease (positive PPD without TB disease is not exclusionary)
* Use of prohibited medications within 14 days prior to study entry (refer to the protocol for a list of prohibited medications)
* Fetus detected to have serious congenital malformation (ultrasound not required to rule out this condition)
* Current documented conduction heart defect (specialized assessments to rule out this condition are not required; a heart murmur alone and/or type 1 second-degree atrioventricular block \[also known as Mobitz I or Wenckebach\] is not considered exclusionary)
* Known to meet the local standard criteria for treatment of HBV (Note: HBV DNA testing or other specialized assessments are not expected to be performed as part of this study. A woman would be excluded only if this information is documented from other sources and she meets the local standard criteria for HBV treatment based on those assessments.)
* Social or other circumstances that would hinder long-term follow-up, in the opinion of the site investigator
* Currently incarcerated

Late Presenter Inclusion Criteria:

* Age of legal majority for the respective country
* HIV-1 infection, defined as documented positive results from tests performed on one sample at any time prior to Late Presenter Registration
* In labor (from onset/early labor or beyond) or within 5 days after delivery (with day of delivery considered day 0)
* Has provided written informed consent
* Has no plans to move outside of the study site area during the 24 months following delivery
* If delivered, infant alive and healthy (In the case of a multiple birth, a mother-infant pair will be included in the Late Presenter registration only if both/all infants and the mother meet the eligibility criteria. If only one infant of a multiple birth is alive, the M-I pair may be registered if the infant and the mother otherwise meet all of the eligibility criteria.)

Late Presenter Exclusion Criteria:

* Participation in PROMISE in prior pregnancy
* Ingestion of any antiretroviral regimen during current pregnancy (including for solely for PMTCT), according to self report and available medical records (Note: Use of ARVs provided as standard of care for PMTCT during labor/delivery or postpartum prior to Late Presenter registration is not exclusionary.)
* If known: CD4 count \< 350 cells/mm3 or below the country-specific threshold for initiation of treatment, if that threshold is \> 350 cells/mm3, on specimen obtained within 30 days prior to study entry (result not required prior to registration)
* Requires triple ARV therapy (HAART) for own health according to local standard guidelines
* WHO Stage 4 disease
* Prior receipt of HAART for maternal treatment indications (e.g., CD4 \< 350 cells/mm3 or clinical indications); however, could have received ARVs for the sole purpose of PMTCT in previous pregnancies. (Prior PMTCT regimens could have included a triple ARV regimen, ZDV, 3TCZDV and/or sdNVP for PMTCT, as well as use of a short dual NRTI "tail" to reduce risk of NVP resistance.)
* Current or history of TB disease (positive PPD without TB disease is not exclusionary)
* Known positive infant HIV nucleic acid test (NAT) result (result not required prior to registration)
* Fetal demise or early neonatal death (prior to enrollment/registration)
* Fetus detected with serious congenital malformation (ultrasound not required to rule out this condition)
* Life threatening infant illness or birth condition incompatible with life
* If delivered, infant birth weight \< 2.0 kg
* Social or other circumstances which would hinder long-term follow-up, in the opinion of the site investigator
* Current documented conduction heart defect (specialized assessments to rule out this condition are not required; a heart murmur alone and/or type 1 second-degree atrioventricular block (also known as Mobitz I or Wenckebach) is not considered exclusionary)

Postpartum Component Inclusion Criteria:

* Participation in the Antepartum Component or registered as a Late Presenter
* Provided written informed consent
* Has no plans to move outside of the study site area during the 24 months following delivery
* Maternal CD4 count greater than or equal to 350 cells/mm\^3, or greater than or equal to the country-specific threshold for initiation of treatment (if that threshold is greater than 350 cells/mm\^3), from a specimen obtained within 30 days prior to study entry. More information on this criterion can be found in the protocol.
* The following maternal laboratory values within 30 days prior to entry:

  1. Hemoglobin greater than or equal to 7.0 g/dL
  2. WBC greater than or equal to 1,500 cells/mm\^3
  3. ANC greater than or equal to 750 cells/mm\^3
  4. Platelets greater than or equal to 50,000 cells/mm\^3
  5. ALT less than or equal to 2.5 times the upper limit of normal (ULN)
  6. Estimated creatinine clearance of greater than or equal to 60 mL/min using the Cockroft-Gault equation for women
* Infant alive, healthy, less than or equal to 14 days of age, and uninfected (negative HIV NAT result on specimen drawn prior to study entry)
* The following infant lab values on specimen obtained prior to study entry (within 14 days of birth):

  1. Hemoglobin greater than or equal to 10 g/dL
  2. WBC greater than or equal to 1,500 cells/mm\^3
  3. ANC greater than or equal to 750 cells/mm\^3
  4. Platelets greater than or equal to 50,000 cells/mm\^3
  5. ALT less than or equal to 2.5 times the ULN
* For Registered Late Presenters: Confirmed maternal HIV-1 infection, defined as documented positive results from two samples collected at different time points at any time prior to entry. More information on this criterion can be found in the protocol.

Postpartum Component Exclusion Criteria:

* Positive infant HIV NAT result on specimen drawn prior to entry or no infant HIV NAT result on specimen drawn prior to entry
* Life-threatening infant illness or birth condition incompatible with life
* Infant birth weight less than 2.0 kg
* Social or other circumstances that would hinder long-term follow-up, as judged by the site investigator
* Current or history of TB disease (positive PPD without TB disease is not exclusionary)
* Current documented conduction heart defect (specialized assessments to rule out this condition are not required; a heart murmur alone and/or type 1 second-degree atrioventricular block \[also known as Mobitz I or Wenckebach\] is not considered exclusionary)
* Requires triple ARV therapy (HAART) for own health

Maternal Health Component Inclusion Criteria:

* Randomly assigned to triple ARV prophylaxis as part of the Postpartum Component and has continued triple ARV prophylaxis until the current randomization without treatment interruption (defined as more than 14 consecutive days of missed dosing) within the previous 30 days; OR randomly assigned to triple ARV prophylaxis in the Antepartum Component but ineligible for the Postpartum Component and has continued triple ARV prophylaxis until the current randomization without treatment interruption (defined as more than 7 consecutive days of missed dosing) within the previous 30 days
* Within two weeks after complete breastfeeding cessation is achieved (defined as completely stopping all exposure to breast milk for greater than or equal to 28 days); i.e., within 29 to 42 days of last breast milk exposure, or reached 18 months postpartum (whichever comes first). Women who reach 18 months postpartum while still breastfeeding will be eligible for entry within 2 weeks before and 4 weeks after the Week 74 visit (Week 72-78); OR if the woman was randomized to triple ARV prophylaxis in the Postpartum Component and her infant is infected and still breastfeeding, she will be eligible for the Maternal Health Component within 42 days of specimen collection for the confirmatory infant HIV NAT; OR if the woman was randomized to triple ARV prophylaxis in the Antepartum Component but mother-infant pair was ineligible for the Postpartum Component she will be eligible for the Maternal Health Component beginning at the Week 1 visit (6-14 days postpartum) through 28 days after delivery; these women should be randomized as soon as possible, ideally within 6-14 days after delivery; OR if the woman was randomized to triple ARV prophylaxis in the Postpartum Component and breastfeeding risk for MTCT ceases for other reasons (e.g., infant death or permanent removal from home through legal services or adoption) within 28 days of event. More information on this criterion can be found in the protocol.
* Provided written informed consent
* CD4 cell count greater than or equal to 350 cells/mm\^3, or greater than or equal to the country-specific threshold for initiation of treatment (if that threshold is greater than 350 cells/mm\^3), on a specimen obtained within 30 days prior to study entry
* The following laboratory values on a specimen obtained within 30 days prior to study entry:

  1. ANC greater than or equal to 750 cells/mm\^3
  2. Hemoglobin greater than or equal to 7.0 gm/dL
  3. Platelet count greater than or equal to 50,000 cells/mm\^3
  4. ALT (SGPT) less than or equal to 2.5 times the ULN
  5. Estimated creatinine clearance of greater than or equal to 60 mL/min using the Cockroft-Gault equation for women
* Intend to remain in current geographical area of residence for the duration of study

Maternal Health Component Exclusion Criteria:

* WHO Stage 4 disease
* Clinically significant illness or condition requiring systemic treatment and/or hospitalization within 30 days prior to study entry
* Current or history of TB disease (positive PPD without TB disease is not exclusionary)
* Use of prohibited medications within 14 days prior to study entry
* Social or other circumstances that would hinder long term follow-up as judged by the site investigator
* Current documented conduction heart defect (specialized assessments to rule out this condition are not required; a heart murmur alone and/or type 1 second-degree atrioventricular block \[also known as Mobitz I or Wenckebach\] is not considered exclusionary)
* Requires a triple ARV regimen for own health

Answer: C