Rapid Systematic Review of Interventions To Improve Antenatal Screening Rates

Received: 11 November 2023 | Accepted: 31 January 2024 | Published online: 23 February 2024
DOI: 10.1002/ijgo.15425
REVIEW ARTICLE
Obstetrics
Rapid systematic review of interventions to improve antenatal

screening rates for syphilis, hepatitis B, and HIV in low-and
middle-income countries
J. Harrison1 | P. Lind2 | S. Sawleshwarkar2,3 | D. Pasupathy1 | H. M. Yapa3
1
Reproduction and Perinatal Centre,
Faculty of Medicine and Health, Abstract
University of Sydney, Camperdown, New
Background: Infectious diseases including syphilis, HIV, and hepatitis B are major con-
South Wales, Australia
2
Sydney Medical School, Faculty of
tributors to maternal and neonatal morbidity and mortality worldwide, especially in
Medicine and Health, University of low-and middle-income countries (LMICs). The World Health Organization has prior-
Sydney, Camperdown, New South Wales,
Australia
itized elimination of vertical transmission of these three diseases.
3
Sydney Infectious Diseases Institute, Objectives: To rapidly assess the impact of interventions designed to improve antena-
Faculty of Medicine and Health, tal screening rates for syphilis, HIV, and hepatitis B in LMICs and to identify areas for
University of Sydney, Camperdown, New
South Wales, Australia future implementation research.
Search Strategy: A comprehensive search was conducted across PubMed, Embase,
Correspondence
J. Harrison, Faculty of Medicine and and EconLit, targeting articles published between January 1, 2013, and June 27, 2023.
Health, Western Sydney (Baludarri) Selection Criteria: We included quantitative interventional studies in English, involv-
Precinct, Corner Hawkesbury Road and
Darcy Road, Westmead, L6 Block K ing pregnant adults (15 years or older) from LMICs. Exclusions were studies based in
Westmead Hospital, The University of high-income countries, qualitative studies, or those investigating accuracy of diagnos-
Sydney, Sydney, NSW 2145, Australia.
Email: [email protected] tic methods.
Data Collection and Analysis: From an initial 5549 potential studies, 27 were finalized
for review after various screening stages. Data extraction covered aspects such as
study design, intervention details, and outcomes. Findings were qualitatively synthe-
sized within a systems thinking framework.
Main Results: The interventions assessed varied in terms of geographic locations,
health care system levels, and modalities. The review highlighted the effectiveness of
interventions such as community health interventions, service quality improvements,
and financial incentives.
Conclusions: The study underscores the potential of specific interventions in enhanc-
ing antenatal screening rates in LMICs. However, there is a discernible research gap
concerning hepatitis B. The findings emphasize the importance of capacity building
and health systems strengthening in public health interventions.
KEYWORDS
antenatal screening, health systems, hepatitis B, HIV, low-and middle-income countries, policy
interventions, syphilis
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2024 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology
and Obstetrics.
Int J Gynecol Obstet. 2024;166:3–26. wileyonlinelibrary.com/journal/ijgo | 3

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4 HARRISON et al.
1 | I NTRO D U C TI O N Although so-called vertical (disease-specific) programs have

been successful in improving health outcomes, holistic interven-
Globally, maternal and neonatal morbidity and mortality account for tions to comprehensively improve antenatal infection screening
a large proportion of the total global burden of disease.1 In 2019, and treatment must be bolstered by health system strengthening.
neonatal disorders accounted for 185.9 million disability-adjusted eMTCT services must be delivered within a broader antenatal care
2
life-years (DALYs). HIV and syphilis contribute significantly to this framework and needs to be complemented by services that supply
total,3 with approximately 150 000 children infected with HIV in medications and manage follow-up. By synthesizing the evidence on
2020,4 and, among 660 000 cases of congenital (vertically acquired) the impact of interventions aimed at improving screening for syph-
syphilis, there were an estimated 350 000 adverse birth outcomes.5 ilis, HIV, and hepatitis B, we hope lessons may be drawn about the
6
Congenital syphilis resulted in approximately 3.6 million DALYs. complementary nature of vertical and horizontal approaches to pub-
HIV was implicated in approximately 47.6 million DALYs.7 Hepatitis lic health interventions.
B resulted in approximately 18.2 million DALYs, 2 with the major-
ity of infections being acquired as a result of vertical transmission
during pregnancy.8 Maternal and neonatal adverse outcomes asso- 2 | AIMS
ciated with syphilis, HIV, and hepatitis B are largely preventable if
diagnosed and adequately treated.9–11 In addition to their significant To assess the impact of interventions to improve coverage for syphi-
contribution to the global burden of disease, syphilis, HIV, and hep- lis, HIV, and/or hepatitis B testing in the antenatal period in LMICs,
atitis B disproportionately impact the global poor, with most associ- as well as identify implementation research priorities.
ated morbidity and mortality occurring in low- and middle-income
countries (LMICs).12
The World Health Organization (WHO) has made a call for Triple 3 | M E TH O D S
12
Elimination of vertical transmission of syphilis, HIV, and hepatitis B.
Given the significant overlap in the epidemiology and transmission 3.1 | Study design
of the diseases, elimination of mother-to-child transmission (eMTCT)
of these three diseases has been identified as a cost-effective and We conducted a rapid systematic review on interventions to im-
13
urgent public health priority. The goal of eMTCT programs is to prove screening rates of syphilis, HIV, and hepatitis B in LMICs.
control incidence to a level at which these infections are no longer The rationale was to conduct a rapid synthesis and generate infor-
a public health concern. The WHO encourages countries that have mation relevant to policymakers and implementation scientists, to
successfully achieved these eMTCT targets to be validated as having identify urgent implementation research gaps, and opportunities
done so, with 16 countries to date being validated for elimination of to scale-up antenatal testing for these three WHO priority dis-
at least one of these conditions.12 eases.19–21 We report our findings according to PRISMA (Preferred
Maternal syphilis, HIV, and hepatitis B share common at-risk Reporting Items for Systematic Reviews and Meta-A nalyses)
populations and modes of transmission. Each may be asymptomatic guidelines. 22
during its initial stages, resulting in diagnostic and treatment delays.
If unrecognized and untreated, each carries a risk of vertical or hor-
izontal transmission, in addition to maternal morbidity. These infec- 3.2 | Search strategy
tions additionally are exacerbated by socioeconomic circumstances
limiting access to diagnosis and treatment, and further reinforcing We searched PubMed, Embase, and EconLit for articles published
the propagation of infection. A diagnosis of syphilis, HIV, or hepatitis between January 1, 2013, and June 27, 2023, inclusive. The data-
B carries with it significant stigma.14–16 Further, the consequences bases were searched using key words and relevant synonyms for
and transmission of these infections are avoidable with adequate pregnancy, LMICs, intervention, testing, syphilis, HIV, and hepatitis
access to health care. B (Appendix).
Effective screening programs play a pivotal role in the “cas- One reviewer (J.H.) independently screened titles and abstracts.
cade of care” toward elimination for syphilis, HIV, and hepatitis B. Studies that could not be included or excluded based on title or ab-
Diagnosis is the essential first step to initiate timely and appropriate stract screening were subjected to a full-text review for inclusion.
17
treatment, ultimately achieving disease cure or control. While the Final consensus on article eligibility was reached in discussion with
overall trajectory of screening rates, especially for HIV, have been another member of the author team (H.M.Y.).
positive, there remain significant barriers in achieving the targets
necessary for triple elimination.18 Given the renewed focus on triple
elimination, interventions aimed at improving screening for syphilis, 3.3 | Inclusion criteria
HIV, and hepatitis B will be important in guiding local, national, and
international policy. The shared modes of transmission and propen- We included quantitative interventional studies, including rand-
sity of individuals to be coinfected with one or more diseases makes omized controlled trials (RCTs), cohort studies, before and after
this approach particularly important. studies, and ecological studies. Searches were conducted in
|
HARRISON et al. 5
English, and results included only studies published in the English as unchanged. If statistical significance or confidence intervals were
language. Studies including pregnant adults (15 years or older at not reported, we assumed the reported change (if any) was signifi-
the time of the study) were considered. Only studies conducted cant. Drawing on the Systems Thinking health systems framework, 25
in, or analyzing data from, LMICs were included. The World Bank studies were classified according to their predominant means of en-
list of countries classified as low-income, lower-middle–income, or acting change. Studies were placed into the following categories:
upper-middle–income was used to determine countries considered community health interventions, service quality improvements,
to be an LMIC. 23 health technology interventions, infrastructure improvement, ser-
Any study examining interventions with the primary aim of ef- vice integration, policy change, and incentivization.
fecting coverage rates of testing for syphilis, HIV, and/or hepatitis B
during the antenatal period were included. This may include initial or
repeat testing during a single pregnancy. Interventions that targeted 4 | R E S U LT S
any level of the health care system, or had a focus on community
interventions, were included. We initially identified 5549 potential studies. After a stepwise
screening process, removal of 295 duplicates, and accounting for
unavailable full-text papers, 27 papers were included in the review
3.4 | Exclusion criteria (Figure 1). Study characteristics are presented in Table 1. A summary
of the interventions assessed and quantitative results are shown in
We excluded studies that were entirely based in high-income Table 2. An assessment of study quality using GRADE criteria can be
countries or did not examine the impact of an intervention target- found in Table 3.
ing improvement of antenatal HIV, syphilis, or hepatitis B testing.
Qualitative studies were also excluded. Studies investigating the
characteristics of diagnostic methods such as the sensitivity or spec- 4.1 | Characteristics of included studies
ificity of a specific diagnostic modality were excluded.
The most common study design utilized was a before and after de-
sign (12 studies, 44%). RCTs were the next most common study type,
3.5 | Data extraction being employed in nine studies (33%).
Geographically, Africa was the predominant location for these
The following data were extracted from each of the included studies: studies (22 studies, 82%), with the remainder being conducted in
first author, year of publication, study design, country of interven- Asia and South America. The most common type of intervention was
tion, study period, sample size, disease focus, context, intervention service quality improvement (eight studies, 30%), followed by com-
details, outcome measures, results, risks of bias, and limitations. munity health interventions (six studies, 22%). HIV was the primary
Once eligibility was determined, two reviewers (J.H. and P.L.) in- disease of focus, being measured in 23 studies (85%), syphilis in six
dependently extracted data from separate lists of the included stud- studies (22%), and hepatitis B in two studies (7%).
ies, according to our prespecified data elements, and met regularly
to review methods and ensure reliability.
4.2 | Summary of the evidence
3.6 | Assessment of study quality This review identified 27 studies on a wide variety of interventions,
across differing levels of the health care system. There was sig-
The Grades of Recommendation, Assessment, Development and nificant heterogeneity in the quality and results of studies, making
Evaluation (GRADE) Working Group framework was applied to as- quantitative summation of results difficult.
24
sess study quality of each individual study included in our review.
Grading was guided by the study design, risk of bias, inconsistency,
indirectness, and imprecision in reported outcomes. Community health interventions
Community-based interventions, implemented outside health facili-

3.7 | Analysis of extracted data ties, aim to enhance patient engagement with health care according
to the Systems Thinking framework 25 and accounted for about a
Data were extracted in a standardized format. Due to the hetero- quarter of studies. Two moderate- to high-quality studies explored
geneity of the interventions and outcomes reported, we did not and reported the positive impacts of novel congregation-based ap-
perform a meta-analysis. We classified statistically significant out- proaches to HIV screening rates. Ezeanolue et al.33 highlighted its
comes (at the 5% significance level) as improved or worsened. If effectiveness in destigmatizing HIV testing and boosting screen-
statistical significance was not reached, the outcome was classified ing rates outside traditional systems. Montandon et al.40 confirmed
|
6 HARRISON et al.
Identification of studies via databases and registers
Identification
Records identified from*:
Records removed before
MEDLINE (n = 4 063)
screening:
Embase (n = 1 469)
Duplicate records removed
EconLit (n = 17)
(n = 295)
Records excluded by title and

Records screened
abstract
(n = 5 254)
(n = 4 731)
Texts screened Records excluded by full text

(n = 523) (n = 494)
Screening
Reports assessed for eligibility Reports not retrieved

(n = 29) (n = 2)
Included
Studies included in review

(n = 27)
F I G U R E 1 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram for identification, screening,
and inclusion of studies. *Consider, if feasible to do so, reporting the number of records identified from each database or register searched
(rather than the total number across all databases/registers).
these findings in a follow-up study, noting high screening rates in a plan-do-study-act intervention improved syphilis screening rates
both intervention and control groups. from 93.8% to 99.9%. In contrast, Yapa et al.44 found no significant
Other notable but lower-quality community-based interventions change in repeat HIV screening in a high-burden setting, despite a
42
included those by Nwanja et al., who reported a 200% increase in continuous quality improvement intervention.
HIV screening by engaging traditional birth attendants to conduct Chabikuli,51 Golden,34 and Hagaman35 and colleagues showed
50
screening in the community, and those by Purnamawati et al., positive impacts on screening rates, although their study designs
who improved HIV screening rates by leveraging community health were less robust. Chabikuli et al. focused on enhancing eMTCT ac-
workers to conduct community-based screening. tivities, and Hagaman collaborated with the Ethiopian government
to boost syphilis screening rates. In contrast, Rustagi et al.47 ob-
served no improvement in HIV screenings with their approach.
Service quality improvement
Service quality improvement, which was the most investigated Health technology interventions
(30%), aimed to refine existing services. Interventions included a
range of approaches, including audit-and-feedback, plan-do-study- Three studies investigated the impacts of health technology inter-
act cycles, and continuous quality improvement interventions. ventions. Bull et al.,52 utilizing a tablet-based data system, found no
27
Four studies were classified as moderate-high. Alhassan et al. impact on HIV screening rates. Oliveira-Ciabati et al.43 trialed a bi-
utilized community health committees to enhance antenatal care en- directional text messaging system, which effectively improved HIV
gagement and increase screening rates. Althabe et al. 28 found that and syphilis, but not hepatitis B screening. Ross et al.48 observed
TA B L E 1 Study design and population characteristics of included studies.
Author, year Country Study period Study design Study population Sample size
26
Ajayi, 2021 Nigeria 2016–2017 Before and after Women of reproductive age (15–49 years) who had 11 204 participants
given birth at least once in the 2 years preceding
HARRISON et al.
the study
Alhassan, 201927 Ghana Initial data collection: March 2012– Cluster RCT Primary health facilities credentialed by national 64 primary health
May 2012, Secondary data health body centres
collection: July 2014–October
2014
Althabe, 201928 DRC and Zambia 2016–2017 Cluster RCT Clinics serving ≥300 new pregnant women per year, 26 ANC clinics
ANC providers qualified to perform screening
tests and administer injectable treatments, and
with no existing quality improvement programs
for syphilis detection and management
Bindoria, 201429 India 2011–2012 Before and after All pregnant women who had not been screened 105 650 participants
for HIV and were registered for ANC under the
National Rural Health Mission at the selected
health facilities
Bull, 201829 Tanzania 2014–2015 RCT All pregnant women who attended ANC clinics at the 1530 participants
selected health facilities
Chabikuli, 201329 Nigeria 2007–2008 Before and after Health care facilities that were able to provide 120 537 participants
eMTCT services
Chizoba, 201730 Nigeria 2014–2015 Cohort study Antenatal clinics supported by the US President's 40 clinics
Emergency Plan for AIDS Relief, through the
center for Clinical Care and Clinical Research–
Nigeria in Ebonyi state of Nigeria
Two groups of PHCs were selected: (1) 34 PHCs
willing to implement TAP-In and (2) 40 PHCs
unwilling to implement TAP-In
Twenty facilities from each group were randomly
assigned to the intervention group or the control
group
Dassah, 201531 Ghana Initial data collection: January Before and after All pregnant women who attended ANC clinics at the 15 clinics
2009–April 2009, Secondary selected health facilities
data collection: September The 15 health care facilities were selected based on
2010–December 2010 their ability to provide eMTCT services
De Schacht, 201532 Mozambique Initial data collection: January Before and after Four rural public health care facilities able to provide Four clinics
2011–December 2011, maternal and child health services in southern
Secondary data collection: Mozambique, funded by the Elizabeth Glaser
January 2012–July 2012 Pediatric AIDS foundation
| 7
(Continues)
8
TA B L E 1 (Continued)
|
Author, year Country Study period Study design Study population Sample size
Ezeanolue, 201533 Nigeria 2013–2014 Cluster RCT Churches that were centrally located in a community, 40 clinics
one church per community only
Churches needed to have completed >20 baptisms
per year over the preceding 3 years
Golden, 201834 South Africa 2013–2015 Cohort study Eight intervention and eight control clinics were 16 clinics
selected in one subregion of South Africa,
intervention clinics were “poorly performing” in
retesting women for HIV compared with “better-
performing” clinics as the control group
Hagaman, 202035 Ethiopia 2016–2018 Interrupted time series All women attending government health facilities 4 clinics
analysis within the study catchment region
Herce, 201536 Malawi 2011–2013 Cross-sectional All government health facilities in the five-district 136 health facilities
catchment area
Jones, 201937 Malawi, South 2013–2016 Before and after Health facilities serving >100 patients per month 46 health facilities
Africa,
Tanzania
Kanyuuru, 201538 Kenya 2010–2012 Before and after All facilities within the Bondo district 59 health facilities
Kaufman, 201739 Ethiopia 2005–2011 Before and after Only women who had heard of HIV 20 196 individuals
40
Montandon, 2021 Nigeria 2016–2017 Cohort study Churches in Benue State, Nigeria, if they had 80 congregations
capacity, willingness, and were easily accessible,
including proximity to health facilities
Musarandega, 2020 41 Zimbabwe 2010–2015 Before and after All pregnant women attending government health 1560 health facilities
facilities
Nwanja, 2023 42 Nigeria 2019–2022 Before and after All health facilities and birthing centers in Awaka 869 health facilities
Ibom, Nigeria
Oliveira-Ciabati, 201743 Brazil 2015–2016 Cluster RCT Women aged ≥18 years who were ≤ 20 weeks 20 clinics
pregnant, and were receiving ANC at selected
PHCs
Yapa, 2020 44 South Africa 2015–2017 Cluster RCT Woman aged ≥18 years at delivery who attended 2160 participants
their first antenatal visit at seven nurse-led
Department of Health PHCs
Uwimana, 2013 45 South Africa 2009–2011 Cluster RCT Household members aged ≥18 years within the 3584 participants
Sisonke District in rural South Africa
Smith, 201546 Guatemala 2012–2013 Before and after Pregnant women seeking ANC at the district health 1793 participants
center, health posts of mobile outreach teams
Rustagi, 2016 47 Côte d'Ivoire, Initial data collection: 2013–2014 Cluster RCT Public and nonprofit health facilities with eMTCT 36 facilities
Kenya and Secondary data collection: January services in the study region in each country,
Mozambique 2015–March 2015 within 20 km from a main transport corridor
HARRISON et al.
|
HARRISON et al. 9
ancillary benefits in HIV screening rates when introducing an ante-

natal ultrasonography program.
Abbreviations: ANC, antenatal care; DRC, Democratic Republic of the Congo; eMTCT, elimination of mother to child transmission (of HIV); PHC, primary health clinic; RCT, randomized controlled trial.
770 participants
425 participants
Sample size
Not given
Infrastructure improvement
Three studies assessed the impact of improvements in health care

infrastructure. Musarandega et al.41 reported that a multifaceted
Women <4 months pregnant who lived in the control
lived in the intervention area (Karawang District)

area (Bekasi District) and pregnant women who
All consenting women who received an ultrasound
scan at the ultrasound program at Nawanyago
point-of-care testing (POCT) intervention, including training and

resources for staff, significantly improved HIV screening rates.
Meanwhile De Schacht et al.32 found no improvement in antenatal
screening rates from their POCT intervention. Smith et al.46 inves-
tigated the impact of introducing rapid testing for HIV, syphilis, and
HC III during the study period
Pregnant women aged ≥18 years
hepatitis B into antenatal care in Guatemala, finding significant ef-

fects on HIV screening rates but not syphilis or hepatitis B.
Study population
Service integration
Service integration at the clinic level was the focus of studies by

Bindoria et al. 29 and Uwimana et al.45 Both reported significant im-
provements in HIV screening rates by integrating eMTCT and pri-
mary health care, or TB services, respectfully.
Before and after
Cohort study
Study design
Policy change
RCT
Policy interventions targeted broad population-level changes in the

health system. Four studies, all with low-or very low–quality evidence,
evaluated the effects of such policy changes on antenatal HIV or syph-
ilis screening. Ajayi et al.26 and Kaufman et al.39 observed significant
increases in screening rates from a national policy change from opt-in
May 2018–October 2018
to opt-out testing in Nigeria and Ethiopia, respectively. Dassah et al.31

found no improvement with a policy change to POCT Ghana. Jones
et al.37 found consistent 100% HIV screening rates in Malawi, South
Study period
Africa, and Tanzania following WHO guideline adaptations.

2014–2015
2007–2012
Incentivization
A unique approach was explored in an RCT by Ortiz et al.,49 which

Indonesia
tested the impact of financial incentives on antenatal HIV screening

West Java,
Country
Ecuador
Uganda
decisions. The study found a significant increase in screening rates

when participants were offered a monetary incentive.
4.3 | Quality assessment

TABLE 1 (Continued)
50
Purnamawati, 2018
The quality of the included studies varied. Five (18%) were deemed
Ortiz, 202249
Ross, 2014 48
high quality, five (18%) moderate, ten low (37%), and six very low
Author, year
(26%). Study design and risk of bias were the most common qual-
ity issues. Despite the varied quality, a majority (64.3%) of studies
reported significant positive results.
10
TA B L E 2 Details of implemented interventions and results.

|
Outcome Intervention Effect size and

Author, year Intervention Control Target disease measure outcome Control outcome significance
Ajayi, 202126 Policy change: the 2017 adoption Standard of care HIV Proportion 42.7% 32.8% Nil effect size or test of
of the “opt-out” policy to HIV of women significance reported
testing during ANC. receiving
an HIV
test at any
time during
ANC
Alhassan, 201927 Service quality improvement: Standard of care HIV Number of Mean screening Mean screening Nil effect size reported;
community engagement via women rate increase rate stable from significance as
community health committees to receiving from 40 to 119 101 to 135 reported
promote MCH services. an HIV (P = 0.0067) (P = 0.4551)
test at any
time during
ANC
Althabe, 201928 Service quality improvement: The control group Syphilis Proportion 99.9% 93.8% Nil effect size reported;
syphilis screening with opinion received supplies for of women P < 0.01
leaders, reminders, audit syphilis testing and receiving
and feedback, monitoring treatment only a syphilis
implementation, and supportive test at any
supervision activities via a local time during
site coordinator. ANC
Bindoria, 201429 Service integration: introduction Preintervention HIV Proportion 79.0% 55.4% Nil effect size or test of
of HIV screening into primary conditions, with of women significance reported
health care within a maternal unintegrated HIV receiving
and child health program. This screening being an HIV
involved advocacy, training undertaken test at any
health staff, biannual outreach, time during
initiating facility-based ANC
counseling and testing centers
at health centers, and training
nurses in HIV screening.
HARRISON et al.

HARRISON et al.
Bull, 201829 Health technology: introduction of Standard of care, which HIV Proportion 43.6% 55.2% Rate ratio = 0.85 (95% CI,
the Tanzania Health Information is recording visits in of women 0.27–2.90)
Technology system, a tablet- handwritten paper receiving
based tool for recording and logs an HIV
reporting data on eMTCT during test at any
various maternal visits. The time during
system's main features include ANC
simplifying data collection during
clinic visits, offering instant
feedback to health workers, and
visualizing district-wide data
mapping.
Chabikuli, 201329 Service quality improvement: Standard of care HIV Proportion 92.3% 81.7% Nil effect size reported;
introduction of group HIV of women P < 0.01
pretest counseling, individual receiving
posttest counseling, and same- an HIV
day results. It also emphasized test at any
frequent support supervision time during
with feedback to providers, ANC
and incorporated patient
tracking and community leader
engagement to bolster the
initiative.
Chizoba, 201730 Community health intervention: Standard of care HIV Number of 5346 women 1892 women 95% increase in screening
the TAP-In community health women rates postintervention
intervention involved recruiting receiving (34% difference
and training TBAs through local an HIV between intervention
women leaders and pregnant test at any and control at
women. These TBAs underwent time during baseline); P < 0.01
a 1-day on-site training on HIV ANC in the
testing, counseling, and referrals community
using national guidelines, and
made monthly visits to primary
health care clinics for data
submission, validation, and
restocking of test kits.
| 11
(Continues)
12
|

Dassah, 201531 Policy change: national rollout of Prepolicy Syphilis Proportion 26.9% 18.1% Nil effect size reported;
syphilis POCTs in Ghana. The implementation data of women P = 0.45
policy change included POCTs were used as the receiving
for syphilis testing in ANC control an HIV
clinics. test at any
time during
ANC
De Schacht, 201532 Laboratory infrastructure and Standard-of-c are Syphilis Proportion 80.8% 87.0% Nil effect size reported;
resources: Introduction of an preprogram of women P = 0.28
integrated package of POCT implementation was receiving
quantification of hemoglobin used as control an HIV
and CD4+ T cells, and syphilis test at any
serology within MCH services time during
ANC
Ezeanolue, 201533 Community health intervention: Participants in control HIV Proportion 92% 55% Nil effect size reported;
the “Healthy Beginning group churches were of women P < 0.01
Initiative” in Nigerian churches referred to health receiving
organized special baby facilities for standard an HIV
showers on Sundays, offering care, where they had test at any
health education and on-site access to HIV testing time during
laboratory testing. Aimed at as part of the usual ANC in the
early identification of pregnant practice. community
women, the initiative provided
integrated testing for HIV and
other conditions to diminish the
stigma tied to isolated HIV tests.
Golden, 201834 Service quality improvement: to Standard of care HIV Proportion 120% 95% Nil effect size or test of
boost antenatal HIV retesting. of women significance reported
The intervention redesigned receiving
the process, having a counselor an HIV
identify and test eligible women test at any
preconsultation, with guidance time during
from Quality Improvement ANC, with
Nurse Advisors and monthly repeat
monitoring of performance testing
indicators. counted
again for
the same
individual
HARRISON et al.
TABLE 2 (Continued)

HARRISON et al.
Hagaman, 202035 Service quality improvement: Preintervention Syphilis Proportion 68.5% 54.7% Nil effect size reported;
The study collaborated with conditions of women P < 0.01
Ethiopia's Federal Ministry receiving
of Health on a Quality a syphilis
Improvement initiative that test at any
trained QITs to devise and test time during
local, system-integrated changes ANC
for better service delivery. These
QITs received in-depth coaching
from project staff between
learning sessions.
Herce, 201536 Service quality improvement: the Compared with national HIV Proportion 87% 66% Nil effect size reported;
intervention involved training averages from data of women P < 0.01
and mentoring health workers collected by the receiving
on national guidelines and Ministry of Health an HIV
testing procedures, transitioning test at any
to less frequent sessions once time during
benchmarks were achieved. It ANC
promoted couples' HIV testing
with an “opt-out” approach,
established 36 community-based
women's support groups in
rural areas for health education,
and provided vitamin-fortified
porridge as an incentive.
Additionally, the initiative
worked to strengthen health
and laboratory systems for early
infant HIV diagnosis.
| 13
(Continues)
14
|

Jones, 201937 Policy change: the study examined Preintervention HIV Proportion 100% 100% Nil effect size or test of
the integration of WHO conditions of women significance reported
guidelines into national policies receiving
for preventing mother-to-child an HIV
HIV transmission in Malawi, test at any
South Africa, and Tanzania. time during
By 2016, these countries' ANC
policies aligned with WHO's,
with provisions for pretest
and posttest counseling and
provider-initiated testing in
antenatal care; Malawi notably
adopted certain policies
even before WHO's official
recommendations. The 2006
WHO guidelines also highlighted
the importance of connecting
mothers to routine ART care.
Kanyuuru, 201538 Community health intervention: Preintervention HIV Proportion 75.7 79.2 Nil effect size or test of
in Bondo District, Kenya, conditions of women significance reported
the Reaching Every District receiving
immunization strategy was an HIV
adapted to boost the PMTCT. test at any
By identifying areas with time during
unreached pregnant women and ANC in the
training CHWs for outreach and community
education, monthly community
activities provided prenatal
care and HIV testing, aiming
to enhance eMTCT access and
usage in the community.
HARRISON et al.
TABLE 2 (Continued)

HARRISON et al.
Kaufman, 201739 Policy change: in 2007, Ethiopia Preintervention HIV Proportion 50% 4% Nil effect size or test of
changed its policy for HIV conditions of women significance reported
testing during ANC to an receiving
“opt-out” approach, testing all an HIV
pregnant women unless they test at any
declined, contrasting the earlier time during
“opt-in” method where explicit ANC
consent was needed. The study
evaluated the policy's impact on
HIV testing rates among women,
particularly in relation to their
stigmatizing beliefs about HIV.
Montandon, Community health intervention: Women attending HIV Proportion 99.9% 99.7% Nil effect size or test of
202140 during church services preceding US President's of women significance reported
the “Baby Shower” events, Emergency Plan receiving
clergy invited expectant couples for AIDS Relief– an HIV
for prayers and attendance supported health test at any
at the event, which featured facilities in the time during
group health education, Benue State area. ANC in the
celebrations, health screenings, community
and HIV testing. Church Health
Assistants performed the HIV
tests as per national guidelines
and monitored HIV-positive
pregnant women and their
infants, facilitating their
connection to eMTCT services,
including ART, at their chosen
health facility.
| 15
(Continues)
16
|

Musarandega, Laboratory infrastructure and Preintervention HIV Proportion 99% 80% Nil effect size reported;
2020 41 service quality improvement: conditions of women P < 0.01
provided point-of-c are CD4 receiving
testing equipment and EDTA an HIV
tubes to MNCH facilities test at any
lacking laboratories, funded a time during
nationwide courier service for ANC
early infant diagnosis services,
and started a clinical mentorship
for MNCH nurses to boost ART
initiation confidence. They also
launched a quality improvement
program instructing nurses on
using PDSA cycles to better
PMTCT services and trained
more nurses in rapid HIV testing
while ensuring stock availability.
Nwanja, 2023 42 Community health intervention: Preintervention HIV Number of 39 305 women 127 005 women 223% increase in absolute
the intervention partnered with conditions women screened screened number; nil test of
TBAs in community birth centers receiving preintervention postintervention significance reported
to offer HIV testing to pregnant an HIV
women outside standard health test at any
facilities. Through advocacy time during
and a hub-spoke model linking ANC in the
these centers to primary health community
care units, antenatal days were
established and community ART
teams provided HIV testing.
This ensured accessible HIV
testing for pregnant women
at these centers, addressing
transportation and referral
challenges.
HARRISON et al.
TABLE 2 (Continued)

HARRISON et al.
Oliveira-Ciabati, Health technology intervention: Women attending HIV, syphilis, Proportion Syphilis ≤2: 65.7%, Syphilis ≤2: 75.2%, Nil effect size reported;
201743 the PRENACEL intervention clinics randomized hepatitis B of women Syphilis 3: Syphilis 3: syphilis: P = 0.01, HIV:
offered a bidirectional SMS to control clinics, receiving 34.3%, HIV ≤2: 24.8%, HIV ≤2: P = 0.03, Hepatitis B:
service aiming to promote receiving regular an HIV, 66.9%, HIV 3: 74.3%, HIV 3: P = 0.50
antenatal care practices. Health ANC. syphilis or 33.1%, Hepatitis 25.7%, Hepatitis
care personnel were trained hepatitis B B: 95.7% B: 94.5%
and enrolled pregnant women test at any
received gestational age-specific time during
SMS messages about pregnancy ANC
and childbirth, adapted from the
MAMA program and translated
into Brazilian Portuguese.
Women could interact with
health care providers through
SMS and could opt out anytime,
while still receiving standard
ANC
Yapa, 2020 44 Service quality improvement: using Standard of ANC HIV Proportion 59% 59% Rate ratio: 1.00
continuous quality improvement of women (95% CI, 0.88–1.13)
tools (process maps, fishbone initially
diagrams, run charts, PDSA HIV
cycles and action learning negative
sessions) tailored to local clinic receiving a
needs. repeat HIV
test
Uwimana, 2013 45 Service integration: combination of Standard of care– HIV Proportion 78% 55% Nil effect size reported;
structural adjustment, training of TB-HIV services of women P < 0.01
CHW, harmonization of scope of provided at the receiving
practice, stipend of CHWs and facility level and an HIV
enhanced CHW supervision to community care test at any
provide comprehensive TB-HIV/ workers did not time during
eMTCT services receive additional ANC
training
Smith, 201546 Infrastructure improvement: triple Standard of ANC: no HIV, syphilis, HIV: 50.3% HIV: 20.6% Nil effect size reported;
antenatal screening using POCT testing for hepatitis hepatitis B Syphilis: 50.3% Syphilis: 49.6% HIV: P < 0.01
was introduced through the B offered Hepatitis B: 42.2% Hepatitis: no testing Syphilis: P = 0.87
existing public network of health available
services and outreach teams.
| 17
(Continues)
18
|

Rustagi, 2016 47 Service quality improvement: the Standard of ANC HIV Proportion 90.5% 87.8% Nil effect size reported;
intervention provides a method provided by facilities of women preintervention, preintervention, P = 0.97
for eMTCT staff and facility receiving 95.5% 93.4%
managers to assess service an HIV postintervention postintervention
performance and determine test at any
areas for enhancement. They time during
use process mapping to detect ANC
bottlenecks, implement
solutions, and subsequently
evaluate the impact of these
solutions on the eMTCT cascade.
Ross, 2014 48 Health technology intervention: Standard ANC visits: no HIV Number of 185 tests per month 100 tests per month Nil effect size reported;
ultrasound program using ultrasound offered women P < 0.01
portable ultrasound machines. receiving
A scan is offered at the an HIV
first ANC visit and again at test at any
32 weeks. Images are accessed time during
by a credentialed interviewer ANC
for interpretation. Women
undergoing ultrasound were
opportunistically offered
screening for a range of other
conditions, including screening
for HIV.
Ortiz, 202249 Incentivization: health information Information arm: HIV Proportion 66.70% 9.10% Nil effect size reported;
with or without financial participants received of women P < 0.001 (financial
incentive: women (1) received information about receiving incentive vs control)
a flyer with information about HIV testing and an HIV and P = 0.014 (soft
HIV testing, prevention and the prevention and test at any commitment vs
nearest HIV testing facility, (2) details about the time during control)
were asked to date and initial a nearest testing ANC
form on which they promised to site and were
get tested in the next 15 days as encouraged to get
well as receiving information or tested within 15 days
(3) received testing information
as well as a $10 incentive to get
tested. All participants were
encouraged to get tested within
15 days
HARRISON et al.
|
HARRISON et al. 19
5 | DISCUSSION
Abbreviations: ANC, antenatal care; ART, antiretroviral therapy; CHW, community health worker; CI, confidence interval; eMTCT, elimination of mother-to-child transmission; MAMA, Mobile Alliance for
Nil effect size reported;
Maternal Action; MCH, maternal and child health; MNCH, maternal, newborn, and child health; PDSA, plan-do-study-act; PMTCT, prevention of mother-to-child HIV transmission; POCT, point-of-c are
5.1 | Summary of results
Effect size and
significance
P < 0.01 This systematic review identified 27 studies that described inter-
ventions aiming to improve screening rates for HIV, syphilis, and
hepatitis B in the antenatal period. These interventions were imple-
mented using a variety of modalities and had a predominant focus
on HIV. Interventions targeted differing levels of the health system,
Control outcome
from high-level policy change to quality improvement within clinics.

There was good-quality evidence for service quality improvement,
community-based interventions, and financial incentives improv-
10.60%
ing HIV screening. There was moderate-quality evidence for policy

change on HIV and syphilis and service integration on HIV.
5.2 | Access and quality of health care

Intervention
outcome
85.50%
Accessing and engaging with health care systems is the essential

foundation upon which the cascade of care preventing vertical
transmission of disease rests. Interventions aimed at improving ac-
time during
community
ANC in the
testing; QIT, quality improvement team; TB, tuberculosis; TBA, traditional birth attendant; WHO, World Health Organization.
test at any
receiving
cess to care can increase the absolute number of women reached

women
Number of
an HIV
Outcome
measure
and increase the likelihood of those reached who take up screening.

Shifting the setting in which health care takes place from the clinic
into the community removes several barriers to screening. Ezeanolue
et al.33 and Montandon et al.40 demonstrated the effectiveness of
Target disease
this approach in undertaking HIV education and antenatal screen-

ing in church congregation groups, improving both access to and en-
HIV
gagement with the health care system. This example of a faith-based

intervention points to the importance of local contextual knowledge
in improving access to care and leveraging existing community re-
lationships in a novel and culturally appropriate manner to improve
Standard of ANC
screening rates. Utilization of community health workers is another

means of shifting the locus of care into the community, which has
been shown to be effective in interventions related to vaccination53
Control
or oral-rehydration-solution distribution.53 Two studies included in

this review, by Nwanja42 and Purnamawati50 and colleagues repli-
cated this result with antenatal HIV testing. Economic incentiviza-
provision of health education,
tion provides an alternate lens to increasing access to care, which

Community health intervention:
implementation of HIV tests

for pregnant women in the
may represent an underutilized approach to screening programs.

offering HIV testing and
Strong health systems are essential in ensuring population

health. Health systems are shaped by health policy and fortified by
service quality improvement initiatives. Policy interventions, spe-
community
cifically those focusing on presumed consent, i.e., a shift from an

Intervention
opt-in to an opt-out policy, have been proven effective in various

areas of policy, from retirement savings54 to organ donation.55 The
policy change from opt-in to opt-out were shown to be an effective
TABLE 2 (Continued)
means of improving screening rates by two studies focused on HIV

screening in our review. 26,39 The quality improvement interventions
Purnamawati,
in this review were notably complex and highly contextual. Six of the
Author, year
201850
eight service quality improvement interventions reported significant

improvements in screening rates. The studies of service quality im-
provement highlighted several health system challenges hindering
20
TA B L E 3 Quality of included studies: GRADE criteria.a

|
Risk of
Study, year bias Inconsistency Indirectness Imprecision Quality Justification
26
Ajayi, 2021 Yes No No Yes Low ⊕⊕⊖⊖ Before and after design with a highly relevant intervention,
results based off survey data, with some risk of recall bias
Alhassan, 201927 No No No No High ⊕⊕⊕⊕ Cluster RCT with minimal design flaws with a highly relevant
intervention and outcome
Althabe, 201928 No No No No High ⊕⊕⊕⊕ Cluster RCT with minimal design flaws with a highly relevant
intervention and outcome
Bindoria, 201429 Yes Yes No No Very low ⊕⊖⊖⊖ Before and after study design with high risk of selection
bias, given women who had already been screened were
excluded
Bull, 201829 No Yes No Yes Moderate ⊕⊕⊕⊖ Randomized trial design with difficult-to-interpret statistical
findings and imprecision in respect to outcome of interest
Chabikuli, 201329 Yes No No No Low ⊕⊕⊖⊖ Before and after study design with large sample size and
measures relevant to the research question
Chizoba, 201730 Yes No No Yes Low ⊕⊕⊖⊖ High risk of selection bias in allocating clinics to intervention or
control; no reported proportion of women screened
Dassah, 201531 Yes Yes No Yes Very low ⊕⊖⊖⊖ Before and after study design using routinely collected and
incomplete data
De Schacht, 201532 Yes No No No Low ⊕⊕⊖⊖ Before and after study design with well-collected data, with
highly selected health centers for inclusion
Ezeanolue, 201533 No No No No High ⊕⊕⊕⊕ Randomized trial design with adequate randomization and clear
methodology, clear reporting of findings and highly relevant
Golden, 201834 Yes No No Yes Low ⊕⊕⊖⊖ Cohort design with differing baseline group characteristics
introducing significant risk of bias; raw statistics reported
but no formal analysis
Hagaman, 202035 Yes Yes No Yes Very low ⊕⊖⊖⊖ Interrupted time series analysis with unclear statistical
reporting, unclear accounting for extrinsic factors in
reporting
Herce, 201536 Yes No No No Moderate ⊕⊕⊕⊖ Cross-sectional study with selected study population differing
to background population, clearly reported methods and
results
Jones, 201937 Yes No No Yes Low ⊕⊕⊖⊖ Before and after study design with clear methods, but unclear
reporting of data and results
Kanyuuru, 201538 Yes No No No Low ⊕⊕⊖⊖ Before and after study with clear methodology and results,
unclear statistical reporting of HIV testing outcomes
Kaufman, 201739 Yes No No Yes Very low ⊕⊖⊖⊖ Highly selected study population, methods subject to recall
bias, and unclearly reported results
HARRISON et al.
HARRISON et al.
Risk of
Study, year bias Inconsistency Indirectness Imprecision Quality Justification
40
Montandon, 2021 No No No No Moderate ⊕⊕⊕⊖ Robustly designed cohort study with quality reporting of
methods and results
Musarandega, 2020 41 Yes No No No Moderate ⊕⊕⊕⊖ Before and after study design, not clear data collection was
uniform across sites, large sample with clearly reported
results
Nwanja, 2023 42 Yes Yes No Yes Low ⊕⊕⊖⊖ Before and after design with clear methodology and very
difficult-to-interpret results
Oliveira-Ciabati, 201743 Yes No No No Moderate ⊕⊕⊕⊖ RCT design with potential selection bias in reporting of per-
protocol results, clearly reported methodology and results
Yapa, 2020 44 No No No No High ⊕⊕⊕⊕ RCT design with limited bias in design; clearly reported
methods and results
Uwimana, 2013 45 Yes No Yes Yes Very low ⊕⊖⊖⊖ RCT design with different baseline characteristics between
control and intervention groups; results no specifically
focusing on antenatal care
Smith, 201546 Yes Yes No No Low ⊕⊕⊖⊖ Before and after study design with imperfect resource
availability for intervention implementation; clearly
reported results
Rustagi, 2016 47 No Yes No Yes Low ⊕⊕⊖⊖ RCT design, small sample size with unclearly presented
statistics and statistical analysis
Ross, 2014 48 Yes Yes Yes Yes Very low ⊕⊖⊖⊖ Before and after study; no reported baseline population size,
unclear inclusion criteria
Ortiz, 202249 Yes No No No High ⊕⊕⊕⊕ RCT design with quality randomization strategy; clearly
reported methodology and results
Purnamawati, 201850 Yes No No No Low ⊕⊕⊖⊖ Cohort design with differing baseline group characteristics
introducing significant risk of bias; clearly reported
methods and results
Note: Inconsistency: look for unexplained variability in the results across studies. Indirectness: evidence might be indirect if it does not directly address the research question, if it is from a different
population, or if it uses surrogate outcomes. Imprecision: wide confidence intervals or sparse data can lead to imprecision. Abbreviations: GRADE, Grades of Recommendation, Assessment, Development
and Evaluation; RCT, randomized controlled trial.
a
Risk of bias: assess each study for potential biases, such as selection bias, performance bias, detection bias, attrition bias, and reporting bias.
| 21
|
22 HARRISON et al.
uptake of the intervention, particularly staffing shortages, gaps in articles included a range of interventions in terms of geographic lo-
36,44
health worker knowledge, and limited available resources. The cations, level of health care system, and modalities. We were able
findings emphasize the need for parallel health systems–strength- to focus our review on recent evidence, which remains highly rel-
ening initiatives alongside quality improvement in LMICs. The bene- evant to current policy and planning. In addition, the use of a rapid
fits gained from service quality improvement, while specific to local systematic review design allowed us to draw out important findings
context in their formulation, provide a robust means of ensuring the from this evolving body of literature to be made available as soon as
systems that are accessed by women are providing a high quality of possible.
care, which is continuously improved. A potential limitation of our design is that our search was limited
to the pool of studies reported in English. Given the high level of het-
erogeneity in study design and outcome reporting, we were unable
5.3 | Disease focus disparity to quantitatively summate the results or conduct a meta-analysis.
While the rapid nature of the systematic review design allowed us
HIV became a global health priority after its unprecedented emer- to quickly consolidate results, the process of review and data ex-
56
gence in the 1980s. Funding availability and public awareness of traction may have been improved by undertaking a more traditional
HIV have seen significant improvements in outcomes for those living approach to reviewing articles.
with the disease. 25 While syphilis and hepatitis B likewise present
significant public health challenges, they have received less atten-
tion. This review demonstrates the ongoing focus on HIV as the 5.6 | Research gaps
subject of interest for interventions aiming to increase testing rates
for HIV, syphilis, and hepatitis B. This represents a missed opportu- A few important gaps in the existing literature were identified in
nity to improve the quality of care delivered to women in resource- performing this review. The first and most stark of which is the rela-
46
limited settings. Two studies from this review, Smith et al. and tive paucity of available data on interventions to improve antenatal
Oliveira-Ciabati et al.,43 suggest that interventions may not have uni- screening for hepatitis B. In addition, investigating the impacts of
form impacts across the three diseases. Such limited evidence can interventions and programs over extended periods will be important
be difficult to generalize, but it does, however, highlight the urgent for guiding policy and resource allocation decisions. This is particu-
need to formulate a more comprehensive understanding of the care larly important as more complex interventions (such as quality im-
cascade for syphilis and hepatitis B. provement initiatives, which require behavior change modification)
may exhibit delayed intervention effects or may not be sustained in
the long term.
5.4 | Need for a holistic approach
In order to achieve the targets set out for triple elimination, a health 5.7 | Future directions and policy implications
systems–strengthening approach is essential, while vertical pro-
grams alone are insufficient.57 For instance, infrastructure improve- There is an urgent need to address the unmet gap in preventing ver-
ment interventions are pivotal in improving screening rates but may tical transmission of syphilis, HIV, and hepatitis B. This review has
have limited effectiveness when developed in isolation. De Schacht identified several potentially impactful interventions that were re-
et al.32 found no significant increase in syphilis screening after intro- ported to increase rates of screening for HIV and syphilis. A focus on
41
ducing POCT alone, while Musarandega et al. saw HIV screening interventions that aim to shift the locus of health care delivery closer
rates jump from 80% to 99% by combining POCT with supportive to those who are in need in their communities, or adequately and
systems–strengthening programs. While vertical programs may pre- sustainably incentivize individuals to take up screening campaigns,
sent a more tractable and scalable approach to addressing public are potential means of improving access to care. Within health care
health issues, evidence for their positive long-term and sustainable settings, ensuring quality improvement and service integration pro-
impact are limited.58 Service integration offers an approach that jects equitably include relatively neglected syphilis and hepatitis B
blends focused disease-oriented vertical programs into a broader programs will be essential. To ensure sustained improvements, con-
health systems–strengthening approach,59 which has seen success current health systems–strengthening initiatives will be required.
60
in combined tuberculosis-HIV care and shows promise for eMTCT Health technologies such as POCT play an important role in remov-
interventions. ing barriers to screening, but must be implemented with sufficient
infrastructure, logistical support, and training for staff.
At a higher level, policy interventions are likely to be a very im-
5.5 | Strengths and limitations pactful means of change on a large scale. Changing screening for
HIV, syphilis, and hepatitis B to an opt-out system provides a widely
This systematic review has several strengths. These include the applicable behavioral intervention that may improve screening rates
broad sample of papers included in the initial search and selected overnight, with sufficient resourcing. If triple elimination of HIV,
|
HARRISON et al. 23
syphilis, and hepatitis B is to be our goal, it is important for funders, AC K N OW L E D G M E N T S

policy makers, and researchers to consider the three diseases as Open access publishing facilitated by The University of Sydney,
components of a single broader goal. Manufacturers of rapid HIV, as part of the Wiley - The University of Sydney agreement via the
syphilis, and hepatitis B testing kits could consider producing three- Council of Australian University Librarians.
in-one testing cassettes, as current duo-test kits exist for HIV and
syphilis.61 Consideration of better coordination across vertical dis- F U N D I N G I N FO R M AT I O N
ease–based programs, with view to service integration and consoli- This project received no funding.
dation, will be key in leveraging scarce resources and maximizing the
impact from MTCT of syphilis, HIV, and hepatitis B, and is aligned C O N FL I C T O F I N T E R E S T S TAT E M E N T
59
with WHO priorities. At the most foundational level, the strength- No authors have any conflict of interest to declare.
ening of health systems will ultimately be required to ensure reliable,
and sustainable, improvements in outcomes for mothers and chil- DATA AVA I L A B I L I T Y S TAT E M E N T
dren, moving toward triple elimination. Data sharing is not applicable to this article as no new data were cre-
This study did not investigate or collect data on the cost- ated or analyzed in this study.
effectiveness of various interventions. When considering the impli-
cations for policy and practice of the interventions included in this ORCID
review, it is important to be mindful of the secondary or unmeasured J. Harrison https://orcid.org/0000-0002-4102-5453
effects these programs may have on other aspects of the health
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PLoS One. 2015;10(8):e0135744. tives, not behavioral nudges, led to optimized HIV testing among
|
HARRISON et al. 25
pregnant women in a high-burden urban population in Ecuador. Am APPENDIX

J Trop Med Hyg. 2022;106(6):1703-1710.
50. Purnamawati D, Djuwita R, Siregar K, et al. Improving access to
Search Methods for Identification of Studies
PMTCT services via a novel implementation model: organiza-
tional support, health education, and HIV testing at the com- To locate relevant studies, a search will be conducted using the
munity level of West Java, Indonesia. Int J Health Promot Educ. MEDLINE/PubMed and Embase, EconLit databases. The search
2020;58(5):282-292. strategy will be developed through the use of MeSH terms for
51. Chabikuli ON, Gwarzo U, Olufunso A, et al. Closing the preven-
MEDLINE/PubMed, Emtree terms for Embase and keywords related
tion of mother-to-child transmission gap in Nigeria: an evaluation
of service improvement intervention in Nigeria. S Afr Fam Pract. to pregnancy, coverage, STIs and LMICs.
2013;55(1):96-102.
52. Bull S, Thomas DS, Nyanza EC, Ngallaba SE. Tanzania health infor- Databases: MEDLINE/PubMed, Embase, EconLit
mation technology (T-HIT) system: pilot test of a tablet-based sys-
Search phrasing
tem to improve prevention of mother-to-child transmission of HIV.
JMIR Mhealth Uhealth. 2018;6(1):e16. Key words
53. Gibson E, Zameer M, Alban R, Kouwanou L. Community Population:
health workers as vaccinators: a rapid review of the global
landscape, 2000-2021. Global Health, Science and Practice.
• Pregnant women: Pregnancy OR “Pregnant woman” OR pregnan*
2023;11(1):e2200307.
54. Deetlefs A, Bateman H, Dobrescu L, Newell B, Ortmann A, Thorp S. OR ANC OR antenatal OR “mother to child” OR MTCT OR vertical
Engagement with retirement savings: it is a matter of trust | request • LMICs: afghan* OR africa* OR albania* OR algeria* OR angola*
PDF. J Consum Aff. 2018;53(2):917-945. OR antigua* OR barbuda* OR argentin* OR armenia* OR aruba*
55. Molina-Pérez A, Rodríguez-Arias D, Delgado J. Differential impact of
OR azerbaijan* OR bahrain* OR bangladesh* OR bengal* OR
opt-in, opt-out policies on deceased organ donation rates: a mixed
bangal* OR barbados* OR barbadian* OR bajan OR bajans OR
conceptual and empirical study. BMJ Open. 2022;12(9):e057107.
56. Goga AE, Dinh TH, Essajee S, et al. What will it take for the global plan belarus* OR belorus* OR byelarus* OR byelorus* OR belize* OR
priority countries in Sub-Saharan Africa to eliminate mother-to-child benin* OR dahomey OR bhutan* OR bolivia* OR bosnia* OR
transmission of HIV? BMC Infect Dis. 2019;19(Suppl 1):783. herzegovin* OR botswan* OR batswan* OR bechuanaland* OR
57. Atun R, de Jongh T, Secci F, Ohiri K, Adeyi O. Integration of targeted
brazil* OR brasil* OR bulgaria* OR burkina* OR burkinese* OR
health interventions into health systems: a conceptual framework
for analysis. Health Policy Plan. 2023;25(2):104-111. upper volta* OR burundi* OR urundi* OR cabo verde* OR cape
58. Atun R, Bennett S, Duran A. When Do Vertical (Stand- Alone) verde* OR cambodia* OR kampuchea* OR khmer* OR camer-
Programmes Have a Place in Health Systems? World Health oon* OR cameroun* OR ubangi shari* OR chad* OR chile* OR
Organisation; 2008.
china* OR chinese OR colombia* OR comoro* OR comore* OR
59. Bekker L, Alleyne G, Baral S, et al. Advancing global health and
strengthening the HIV response in the era of the Sustainable comorian* OR mayotte* OR congo* OR zaire* OR costa rica*
Development Goals: the International AIDS Society-L ancet OR "cote d'ivoir*" OR "cote d' ivoir*" OR cote divoir* OR cote
Commission. Lancet. 2018;392(10144):312-358. d ivoir* OR ivory coast* OR ivorian* OR croatia* OR cuba OR
60. Kufa T, Fielding K, Hippner P, et al. An intervention to optimise the
cuban OR cubans OR "cuba's" OR cyprus* OR cypriot* OR czech*
delivery of integrated tuberculosis and HIV services at primary care
clinics: results of the MERGE cluster randomised trial. Contemp Clin OR djibouti* OR french somaliland* OR dominica* OR ecuador*
Trials. 2018;72:52. OR egypt* OR united arab republic* OR el salvador* OR salva-
61. Rodriguez PJ, Roberts DA, Meisner J, et al. Cost-effectiveness of doran* OR guinea* OR equatoguinea* OR eritrea* OR estonia*
dual maternal HIV and syphilis testing strategies in high and low
OR eswatini* OR swaziland* OR swazi* OR swati* OR ethiopia*
HIV prevalence countries: a modelling study. Lancet Glob Health.
2021;9(1):e61-e71. OR fiji* OR gabon* OR gabonese* OR gabonaise* OR gambia* OR
((georgia OR georgian OR georgians) NOT (atlanta OR california
OR florida)) OR ghana* OR gibraltar* OR greece* OR greek* OR
S U P P O R T I N G I N FO R M AT I O N grecian* OR grenada* OR grenadian* OR guam* OR guatemala*
Additional supporting information can be found online in the OR guyana* OR guiana* OR guyanese* OR haiti* OR hispaniola*
Supporting Information section at the end of this article. OR hondura* OR hungary* OR hungarian* OR india* OR indone-
sia* OR iran* OR iraq* OR isle of man* OR jamaica* OR jordan*
OR kazakh* OR kenya* OR karabati* OR korea* OR kosovo* OR
kosova* OR kyrgyz* OR kirgiz* OR kirghiz* OR laos OR lao OR
How to cite this article: Harrison J, Lind P, Sawleshwarkar S,
laotian* OR latvia* OR lebanon* OR lebanese* OR lesotho* OR
Pasupathy D, Yapa HM. Rapid systematic review of
lesothan* OR lesothonian* OR basutoland* OR mosotho* OR
interventions to improve antenatal screening rates for syphilis,
basotho* OR liberia* OR libya* OR jamahiriya* OR lithuania*
hepatitis B, and HIV in low-and middle-income countries. Int J
OR macedonia* OR madagasca* OR malagasy* OR malawi* OR
Gynecol Obstet. 2024;166:3-26. doi:10.1002/ijgo.15425
nyasaland* OR malaysia* OR malay* federation OR maldives* OR
maldivian* OR indian ocean OR mali OR malian* OR "mali's" OR
|
26 HARRISON et al.
malta OR maltese* OR "malta's" OR micronesia* OR marshallese* population* OR underserved countr* OR underserved nation*
OR kiribati* OR marshall island* OR nauru OR nauran OR na- OR underserved population* OR under served population* OR
uruans OR "naurian's" OR mariana OR marianas OR palau OR under served nation* OR under served population* OR deprived
paluan* OR tuvalu* OR mauritania* OR mauritan* OR mauritius* countr* OR deprived population* OR high burden countr* OR
OR mexico* OR mexican* OR moldova* OR moldovia* OR mon- high burden nation* OR countdown countr* OR countdown na-
gol* OR montenegr* OR morocco* OR moroccan* OR ifni OR tion* OR poor countr* OR poor nation* OR poor population* OR
mozambique* OR mozambican* OR myanmar* OR burma* OR poor world OR poorer countr* OR poorer nation* OR poorer
burmese OR namibia* OR nepal* OR new caledonia* OR neth- population* OR poorer world OR developing econom* OR less
erlands antill* OR nicaragua* OR niger* OR oman OR omani OR developed econom* OR underdeveloped econom* OR under de-
omanis OR "oman's" OR pakistan* OR palestin* OR gaza* OR veloped econom* OR middle income econom* OR low income
west bank* OR panama* OR paraguay* OR peru OR peruvian* econom* OR lower income econom* OR low gdp OR low gnp
OR "peru's" OR philippine* OR philipine* OR phillipine* OR phil- OR low gross domestic OR low gross national OR lower gdp OR
lippine* OR filipino* OR filipina* OR poland* OR polish OR pole lower gnp OR lower gross domestic OR lower gross national OR
OR poles OR portugal* OR portuguese OR puerto ric* OR roma- lmic OR lmics OR third world OR lami countr* OR transitional
nia* OR russia* OR ussr* OR soviet* OR rwanda* OR rwandese countr* OR emerging econom* OR emerging nation*
OR ruanda* OR ruandese OR samoa* OR navigator island* OR
pacific island* OR polynesia* OR "sao tome and principe*" OR Intervention: Intervention* OR Program* OR RCT* OR Trial* OR
sao tomean* OR santomean* OR saudi arabia* OR saudi OR sau- "Randomized Controlled Trial" OR "Randomized Controlled Trials"
dis OR senegal* OR serbia* OR seychell* OR sierra leone* OR OR "Quasi-E xperiment" OR "Quasi-E xperiments" OR Observational
slovak* OR sloven* OR melanesia* OR solomon island* OR nor- Study* OR "Observation Study" OR "Cohort Study" OR "Cohort
folk island* OR somali* OR sri lanka* OR ceylon* OR "saint kitts Studies" OR "Program Evaluation" OR "Program Evaluations”
and nevis*" OR "st kitts and nevis*" OR kittian* OR nevisian* OR
saint lucia* OR st lucia* OR saint vincent* OR st vincent* OR • Testing: Test* OR coverage OR screening OR assay OR
vincentian* OR grenadine* OR sudan* OR surinam* OR syria* OR serodiagnosis
tajik* OR tadjik* OR tadzhik* OR tanzania* OR tanganyika* OR
thai* OR timor leste* OR east timor* OR timorese* OR togo OR Control: No control
togoles* OR "togo's" OR tonga* OR trinidad* OR tobago* OR tu- Outcome: Testing rates for:
nisia* OR turkiy* OR turkey* OR turk OR turks OR turkish OR
turkmen* OR uganda* OR ukrain* OR uruguay* OR uzbek* OR • Syphilis: syphilis OR “treponema pallildum” OR “T. pallidum” OR
vanuatu* OR new hebrides* OR venezuela* OR vietnam* OR viet pallidum
nam* OR yemen* OR yugoslav* OR zambia* OR zimbabwe* OR • HIV: HIV OR “Human Immunodeficiency Virus” OR
rhodesia* OR arab* countr* OR middle east* OR global south “Immunodeficiency Virus, Human” OR “Immunodeficiency Viruses,
OR sahara* OR subsahara* OR magreb* OR maghrib* OR west Human” OR “Virus, Human Immunodeficiency” OR “Viruses,
indies* OR caribbean* OR central america* OR latin america* Human Immunodeficiency” OR “Human Immunodeficiency
OR south america* OR central asia* OR north asia* OR northern Viruses” OR “Human T Cell Lymphotropic Virus Type III” OR
asia* OR southeastern asia* OR south eastern asia* OR south- “Human T-Cell Lymphotropic Virus Type III” OR “Human T-Cell
east asia* OR south east asia* OR west asia* OR western asia* Leukemia Virus Type III” OR “Human T Cell Leukemia Virus Type
OR east europe* OR eastern europe* OR developing countr* OR III” OR “LAV-HTLV-III” OR “Lymphadenopathy-Associated Virus”
developing nation* OR developing population* OR developing OR “Lymphadenopathy Associated Virus” OR “Lymphadenopathy-
world OR less developed countr* OR less developed nation* OR Associated Viruses” OR “Virus, Lymphadenopathy-Associated”
less developed world OR lesser developed countr* OR lesser OR “Viruses, Lymphadenopathy-Associated” OR “Human T
developed nation* OR lesser developed world OR under devel- Lymphotropic Virus Type III” OR “Human T-Lymphotropic Virus
oped countr* OR under developed nation* OR under developed Type III” OR “AIDS Virus” OR “AIDS Viruses” OR “Virus, AIDS” OR
world OR underdeveloped countr* OR underdeveloped nation* “Viruses, AIDS” OR “Acquired Immune Deficiency Syndrome Virus”
OR underdeveloped world OR middle income countr* OR middle OR “Acquired Immunodeficiency Syndrome Virus” OR “HTLV-III”
income nation* OR middle income population* OR low income • Hepatitis B: Hepatitis B, viral hepatitis, hepatitis
countr* OR low income nation* OR low income population* OR
lower income countr* OR lower income nation* OR lower income Study type: Interventional

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Received: 11 November 2023 | Accepted: 31 January 2024 | Published online: 23 February 2024

Rapid systematic review of interventions to improve antenatal

J. Harrison1 | P. Lind2 | S. Sawleshwarkar2,3 | D. Pasupathy1 | H. M. Yapa3

Int J Gynecol Obstet. 2024;166:3–26. ﻿ wileyonlinelibrary.com/journal/ijgo | 3

1 | I NTRO D U C TI O N Although so-­called vertical (disease-­specific) programs have

Community-­based interventions, implemented outside health facili-

Identification of studies via databases and registers

Records excluded by title and

Texts screened Records excluded by full text

Reports assessed for eligibility Reports not retrieved

Studies included in review

ancillary benefits in HIV screening rates when introducing an ante-

Three studies assessed the impact of improvements in health care

lived in the intervention area (Karawang District)

point-­of-­care testing (POCT) intervention, including training and

hepatitis B into antenatal care in Guatemala, finding significant ef-

Service integration at the clinic level was the focus of studies by

Policy interventions targeted broad population-­level changes in the

to opt-­out testing in Nigeria and Ethiopia, respectively. Dassah et al.31

Africa, and Tanzania following WHO guideline adaptations.

A unique approach was explored in an RCT by Ortiz et al.,49 which

tested the impact of financial incentives on antenatal HIV screening

decisions. The study found a significant increase in screening rates

4.3 | Quality assessment

TA B L E 2 Details of implemented interventions and results.

Outcome Intervention Effect size and

Outcome Intervention Effect size and

Outcome Intervention Effect size and

Outcome Intervention Effect size and

Outcome Intervention Effect size and

Outcome Intervention Effect size and

Outcome Intervention Effect size and

Outcome Intervention Effect size and

Outcome Intervention Effect size and

from high-­level policy change to quality improvement within clinics.

ing HIV screening. There was moderate-­quality evidence for policy

5.2 | Access and quality of health care

Accessing and engaging with health care systems is the essential

cess to care can increase the absolute number of women reached

and increase the likelihood of those reached who take up screening.

this approach in undertaking HIV education and antenatal screen-

gagement with the health care system. This example of a faith-­based

screening rates. Utilization of community health workers is another

or oral-­rehydration-­solution distribution.53 Two studies included in

tion provides an alternate lens to increasing access to care, which

implementation of HIV tests

may represent an underutilized approach to screening programs.

Strong health systems are essential in ensuring population

cifically those focusing on presumed consent, i.e., a shift from an

opt-­in to an opt-­out policy, have been proven effective in various

means of improving screening rates by two studies focused on HIV

eight service quality improvement interventions reported significant

TA B L E 3 Quality of included studies: GRADE criteria.a

syphilis, and hepatitis B is to be our goal, it is important for funders, AC K N OW L E D G M E N T S

pregnant women in a high-­burden urban population in Ecuador. Am APPENDIX

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Int J Gynecol Obstet. 2024;166:3–26. wileyonlinelibrary.com/journal/ijgo | 3

1 | I NTRO D U C TI O N Although so-called vertical (disease-specific) programs have

Community-based interventions, implemented outside health facili-

point-of-care testing (POCT) intervention, including training and

Policy interventions targeted broad population-level changes in the

to opt-out testing in Nigeria and Ethiopia, respectively. Dassah et al.31

from high-level policy change to quality improvement within clinics.

ing HIV screening. There was moderate-quality evidence for policy

gagement with the health care system. This example of a faith-based

or oral-rehydration-solution distribution.53 Two studies included in

opt-in to an opt-out policy, have been proven effective in various

pregnant women in a high-burden urban population in Ecuador. Am APPENDIX