Assessing the Reach, Adoption, Implementation, and Maintenance of the Systems Analysis and Improvement Approach for prevention of mother-to-child transmission of HIV in Manica Province, Mozambique 2018-2021 (the SAIA-SCALE Program)
Authors: Crocker Jonny , Ásbjörnsdóttir Kristjana , Coutinho Joana , Agostinho Mery , Amaral Fernando , Cruz Emilia , Cuembelo Fatima , Dinis Aneth , Feijão Esperança Tavede , Fernandes Quinhas , Gimbel Sarah , Hazim Carmen , Inguane Celso , Isidoro Xavier Alcides , Murgorgo Filipe , Nassiaca Regina , Ramiro Isaias , Ronen Keshet , Sidat Yadesh , Weiner Bryan , Sherr Kenneth 
Published: June 2022

Abstract
BACKGROUND Optimal delivery of prevention of mother to child transmission of HIV (PMTCT) programs is challenging, including in Mozambique. The Systems Analysis and Improvement Approach (SAIA) is a multi-component, systems engineering strategy that has demonstrated PMTCT cascade improvement in a previous cluster randomized trial. To facilitate scale-up and improve integration into routine management systems, the SAIA-SCALE trial (NCT03425136) evaluates delivery of SAIA to health facilities by maternal and child health district supervisors, with minimal external support. SAIA-SCALE uses the RE-AIM framework to evaluate essential ingredients for public health impact that are infrequently reported. In this article we report intervention reach, adoption, implementation, and maintenance.METHODS SAIA-SCALE is a stepped-wedge trial in 36 facilities covering all 12 districts of Manica province, central Mozambique, from 2018—2021. Each district received a one-year intensive phase with external research staff support and financial support, followed by a maintenance phase with only limited financial support. We used data from health management information systems and implementation tracking to assess reach, adoption, implementation, and maintenance of the SAIA strategy using descriptive statistics.RESULTS SAIA-SCALE reached 36 facilities covering over 146,000 institutional births and 206,000 first antenatal care visits during the study period. Mean scores on two organizational readiness predictors of adoption were 4.82/5 for change commitment and 4.78/5 for change efficacy. Program adoption was 100%—all 12 targeted districts attended initial training, and all targeted 36 facilities initiated the SAIA strategy. Intensive and maintenance phases comprised equal facility-months. Each facility received an average of 1.1 and 1.0 mentorship visits per month from district supervisors during the intensive and maintenance phases, respectively. Across all facilities, 429 workplans were developed during the intensive and 432 during the maintenance phase. Facility staff reported implementing 91.8% of intensive phase workplans, and 85.9% of maintenance phase workplans. Facilities reported adopting into routine practice 70% and 62% of micro-interventions tested during the intensive and maintenance phases, respectively.CONCLUSIONS Assessment of reach, adoption, implementation, and maintenance revealed the successful integration of a systems engineering strategy for PMTCT into routine healthcare management systems in Mozambique. R-AIM should more frequently be reported alongside effectiveness for a deeper understanding of sustained public health impact of HIV prevention programs.Trial registration:ClinicalTrials.gov NCT03425136 (registered 02/06/2018).