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Background Reducing perinatal HIV transmission and optimizing maternal and child health (MCH) outcomes in high HIV prevalence settings is an urgent, but complex, priority. Extant interventions over-emphasize individual-level provider and patient behaviors, and neglect critical health systems-level changes. The ‘Integrated Management Team to Improve Maternal-Child Outcomes (IMPROVE)’ study implemented a three-part, patient-centered, health-systems-level intervention to improve MCH and HIV outcomes in Lesotho. Ensuring intervention fit within the health systems context is important, but often overlooked. This manuscript describes implementation research conducted to tailor and adapt intervention implementation to optimize appropriateness, acceptability, and feasibility. It identifies resulting implementation variation across study sites and lessons learned. Methods The research team reviewed intervention implementation documentation and conducted structured reflections to: 1) assess implementation strategy adaptations, 2) identify facility-specific strategies employed to improve the MCH patient experience, and 3) synthesize lessons. Results Facility-based, integrated, multi-disciplinary management teams (MDT) were feasible and acceptable to establish through engagement with facility leadership and facilitation of a participatory training curriculum that established shared values between cadres supporting MCH, and identified facility-specific service delivery gaps and potential solutions. Ongoing MDT meetings provided coordination between facility and community-based MCH service providers to implement early ANC follow-up. Facility-specific improvement strategies included fee, staffing, and patient documentation-based changes. Piloting Positive Health, Dignity, and Prevention-focused counseling approaches resulted in tailored job aids pre-implementation. Leadership involvement was critical for improved coordination while staff turnover and competing donor priorities challenged MDT efforts. Conclusions IMPROVE created facility-specific adaptation opportunities through participatory intervention implementation practices. The MDTs, benefitting from leadership support, built relationships between HCW cadres, led facility-specific quality improvements, and, importantly, offered HCWs sought-after positive feedback by recognizing HCW efforts. The coordination, monitoring and cross-cadre communication functions of the MDTs supported implementation of other interventions, and may serve as a valuable platform for improving patient-centered care practices in similar settings and for other health services. Trial registration number: NCT04598958, 05 October 2020, retrospectively registered. Trial registration ClinicalTrials.gov, NCT04598958. Registered 05 October 2020—Retrospectively registered, https://clinicaltrials.gov/ct2/show/record/NCT04598958

Even in the context of widespread access to prevention of vertical HIV transmission (PVT) services, health system challenges compromise health outcomes for women living with HIV and their children. The \"Integrated Management Team to Improve Maternal-Child Outcomes\" (IMPROVE) study measured the effect of a package of facility-based interventions on PVT and maternal and child health (MCH) outcomes in Lesotho. This cluster-randomized study included six facilities randomized to the standard-of-care and six to the IMPROVE intervention. The intervention included multidisciplinary teams of health care and community workers providing MCH support, training in patient-centered care, and additional home support. Pregnant women with and without HIV were enrolled at their first antenatal visit and followed through 12-24 months postpartum with their infants. Data were collected through participant interviews and routine medical record abstraction. Primary outcomes included viral suppression and adherence to antiretroviral therapy (ART) for women with HIV and repeat HIV testing for women without HIV. Analysis utilized generalized estimating equations (GEE) adjusted for intra-site correlation. Between July 2016 and February 2017, 614 pregnant women with HIV and 390 without HIV were enrolled. At 12 months postpartum, over 90% of women with HIV with viral load (VL) testing had a VL < 1,000 copies/mL; the intervention arm had a trend toward higher proportion with undetectable VL (< 50 copies/mL) compared to the control arm [83% versus 72%, OR 1.9 (95% CI 0.86-4.14)]. Women with HIV in the intervention arm had significantly higher odds of consistent adherence to ART [OR 1.81 (95% CI 1.03-3.18)], and women without HIV in the intervention arm had significantly higher odds of being re-tested for HIV prior to delivery [OR 1.95 (95% CI 1.23-3.08)]. Sites that implemented the IMPROVE intervention documented better PVT and MCH outcomes than sites implementing standard-of-care. This package of facility-based interventions is a promising and easily scalable model for improving coordination, quality, and uptake of services within the existing health system.