Listening to health workers: lessons from Eastern Uganda for strengthening the programme for the prevention of mother-to-child transmission of HIV

'I no longer worry about money for transport to the health centre' - economic empowerment of caregivers of children living with HIV through Village Savings and Loan Associations: experiences and lessons from the 'Towards an AIDS Free Generation Program in Uganda (TAFU)'

BACKGROUND

In Uganda, social economic challenges continue to hinder attainment of HIV prevention and treatment targets for children. Aidsfonds and partners in Uganda implemented an eight-year 'Towards an AIDS Free Generation in Uganda' (TAFU) programme in central, western and eastern, Uganda with Village Savings and Loan Associations (VSLAs) as a key component. In this paper we document experiences of caregivers, children and health workers and lessons learnt from VSLAs as part of the TAFU programme in Uganda.

METHODOLOGY

A qualitative case study was conducted between July and August 2022 in Ntungamo, Kyenjojo Mityana, Mubende and Soroti, districts. Data were collected through 31 focus group discussions (FGDs) with VSLA members, children and adolescents living with HIV, networks of people living with HIV and Village Health Team members (VHTs). In addition, we conducted 11 interviews with children and their caregivers at TAFU supported health facilities as well as 43 interviews with health workers and district officials involved in HIV programming. Content thematic approach was used for data analysis.

RESULTS

The VSLAs under the TAFU programme were a source of economic resources in form of loans for income generation activities and to pay for health care costs which facilitated access to HIV care for children. Members developed lasting friendships and networks of support which helped them to meet the material and psychological needs of children. The VSLA groups provided safe spaces for caregivers to share challenges and to learn more about HIV prevention and treatment from expert clients which improved the care for children living with HIV. Group training, integration of expert clients in VSLA groups, provision of VSLA kits, provision of financial top-up and linking groups to other service providers were critical success factors. However, poverty, poor leadership characterised by domination by select individuals in decision making, favoritism in giving out loans and lack of transparency in handling group activities as well as the COVID-19 were key challenges.

CONCLUSION

The VSLAs under TAFU were an effective strategy that enabled caregivers to respond to social, economic and psychological barriers that hinder retention of children in HIV care. Such support should be prioritised by policy makers and programme implementers in Uganda and other low income countries.

Understanding Fijian health system challenges in the prevention of mother-to-child transmission of HIV services in the three tertiary hospitals in Fiji

Mother-to-child transmission is the most common route of human immunodeficiency virus transmission in children, which could be prevented with proper treatment and access to care. Health system challenges can impede the effectiveness of prevention of mother-to-child transmission (PMTCT) programmes. We aim to understand the health system challenges to the provision of PMTCT services for pregnant women in three tertiary hospitals in Fiji. Data were collected using in-depth interviews in the three tertiary hospitals and associated health clinics in Fiji between April-May 2013 and February-March 2014. Ethical approvals were obtained. A total of 58 healthcare providers were interviewed including doctors (n = 12), midwives (n = 19), nurses (n = 14), laboratory technicians (n = 5) and counsellors (n = 8). The data were analysed using thematic analysis. We found that the healthcare workers faced a wide range of health system challenges including institutional and human resource challenges. Staff shortage, limited PMTCT training and shortage of supplies were barriers to the quality of PMTCT services. Our findings would be useful in developing strategies to overcome barriers as it would be imperative in improving the quality of PMTCT service provision in Fiji and other similar settings.

'When I receive ARVs through my group, my heart settles': Participants' perceptions and experiences of Friends for Life Circles for Option B+ in Kampala and Mityana Districts, Uganda

The Friends for Life Circles (FLC) was a parallel randomized controlled trial testing the efficacy of a group peer support intervention to support long-term adherence to Option B+ in Kampala and Mityana districts in Uganda. We explored FLC participants' experiences and perceptions of the intervention on adherence to Option B+ for PMTCT and potential implications for strengthening the PMTCT program. We collected data from six focus group discussions with lactating women enrolled in the FLC intervention, and from 14 key informant interviews with health workers, district and national level stakeholders, as well as male partners of FLC participants. Data were analysed using a content thematic approach in a continuous and iterative process. Women described the FLC intervention as acceptable and beneficial in enhancing their understanding of HIV and the need for ART. The FLC helped women, especially those newly diagnosed with HIV infection to come to terms with their diagnosis and overcome the fear of death linked to testing HIV positive, and provided opportunities to enhance ART initiation, resumption and adherence. The FLC provided safe spaces for women, to learn about ART, and to receive support from peers including adherence reminders through home visits and 'coded' reminder messages. Receiving ART from support groups protected members from stigma and long lines at health facilities. Fear of stigma, health system challenges, the high cost of caring for animals and lack of money to save in groups were key challenges noted. The FLC support groups were crucial in providing needed support for women to initiate, resume and adhere to lifelong ART for Option B+. It is important that women who test HIV positive and start ART for life receive psychosocial support from peers and health workers to improve chances of preventing HIV transmission from mothers to children.

Training, confidence and knowledge of healthcare workers with regard to HIV and infant feeding in eThekwini, South Africa

Background. Healthcare workers play an important role in educating mothers living with HIV regarding appropriate infant and young child feeding (IYCF) practices. However, it is not known if healthcare workers in eThekwini, KwaZulu-Natal (KZN), have been adequately trained regarding IYCF in the context of HIV and how knowledgeable and confident they are. Objectives. To assess the training, confidence and knowledge of healthcare workers regarding IYCF in the context of HIV. Methods. This was a descriptive cross-sectional study, which used a self-administered questionnaire developed for this survey. Healthcare workers (n=188), primarily doctors and nurses in antiretroviral, antenatal and paediatric departments at three regional hospitals (Addington Hospital, Prince Mshiyeni Memorial Hospital and RK Khan Hospital) in eThekwini, KZN, participated. Results. Only 47.3% (n=89) of the participants had attended formal training on IYCF in the context of HIV. Most participants (n=171; 91.4%) felt they required more training. The mean overall confidence score of the group was 4.54 (standard deviation (SD) 1.28)%. The mean knowledge score of participants regarding IYCF in the context of HIV was 51.7%. The attendance of training did not equate to improved knowledge scores. Conclusions. Although the healthcare workers were confident with counselling on IYCF in the context of HIV, their knowledge levels were lower than expected. This could be attributed to a lack of training or outdated or inefficient training. There is a need to improve the coverage and quality of IYCF and HIV training. Training courses should address behaviour change and test for understanding.

Barriers to uptaking HIV testing among pregnant women attending antenatal clinics in low- and middle-income countries: A systematic review of qualitative findings

BACKGROUND

Human immunodeficiency virus (HIV) testing is a gateway to HIV treatment, care and preventive services for pregnant women attending antenatal clinics. Despite this, uptake of HIV testing is not optimal among pregnant women in many low- and middle-income countries (LMICs) and it could negatively impact the effectiveness of prevention of mother-to-child transmission of HIV programs.

AIM

To understand the factors that hinder the uptake of HIV testing among pregnant women attending antenatal clinics in LMICs.

MATERIALS AND METHODS

A systematic search of the CINAHL, EMBASE, JSTOR, Medline, PubMed and Web of Science electronic databases was performed. We limited the search to peer-reviewed qualitative studies including mixed method studies. The titles and abstracts of the retrieved publications were screened for relevance then information was extracted.

RESULTS

Our search yielded 2179 citations, out of which 312 full-text articles were reviewed and 22 studies that met the eligibility criteria were included in this review. We found that a lack of HIV testing kits, poor health infrastructure and shortage of healthcare workers were the main health system-related factors. Poor HIV knowledge, fear of HIV test results, HIV-related stigma and social exclusion negatively influenced pregnant women's decision to be tested for HIV.

CONCLUSION

This review has identified that pregnant women faced a wide range of health system, individual, social and lack of women's empowerment related challenges that negatively influenced the uptake of HIV testing among pregnant women in LMICs. Our findings would be useful in developing strategies to overcome barriers that could enhance the uptake of HIV testing among pregnant women.

Healthcare Workers' Knowledge of HIV-Exposed Infant Feeding Options and Infant Feeding Counseling Practice in Northern Nigeria

BACKGROUND

Despite the existence of evidence-based HIV-exposed infant feeding guidelines, infants in Africa still acquire HIV through inappropriate feeding practices.

OBJECTIVE

To identify predictors of HIV-exposed infant feeding knowledge and counseling practice among health care workers (HCW) in Nigeria.

METHODS

Structured, pretested questionnaires were administered to HCW (n=262) in a tertiary health facility in Kano, Nigeria. Multivariate logistic regression was used to determine predictors of HIV-exposed infant feeding knowledge and counseling practice.

RESULTS

Of 262 respondents, (58.0%, n=152) had good knowledge of recommended feeding options. Respondents listed exclusive breastfeeding (57.6%, n=151), human milk substitutes (45.4%, n=119), HIV-negative wet-nursing (37.0%, n=97), heated expressed human milk (20.6%, n=54) and mixed feeding (13.4%, n=35) as appropriate feeding choices. Over half (57.3%, n=150) of the respondents have ever counseled a HIV-positive mother on infant feeding. Knowledge was predicted by female sex (Adjusted Odds Ratio (AOR)=2.47, 95% Confidence Interval (CI):1.35-4.52), profession (physician vs. laboratory scientist, AOR=4.00, 95%CI:1.25-12.87; nurse/midwife vs. laboratory scientist, AOR=2.75, 95%CI:1.17-9.28), infant feeding counseling training (AOR=3.27, 95%CI:1.87-5.71), and number of children (2-4 vs. 0, AOR=1.75, 95%CI:1.23-3.92). Infant feeding counseling was predicted by female sex (AOR=2.85, 95%CI:1.39-5.85), age (>40 vs. <30 years, AOR=3.87, 95%CI:1.27-15.65), knowledge of infant feeding options (good vs. fair/poor, AOR=3.96, 95%CI:2.07-7.59), training (AOR=2.60, 95%CI:1.42-5.32), and profession (physician vs. laboratory scientist, AOR=10.7, 95%CI:2.85-40.54; nurse/midwife vs. laboratory scientist, AOR=4.8, 95%CI:1.26-18.02).

CONCLUSION

The practice of infant feeding counseling among HCW in Nigeria is associated with sex, knowledge, and profession. Our findings may inform the development of targeted training programs for HCW in similar settings.

Providers' definitions of quality and barriers to providing quality care: a qualitative study in rural Mpumalanga Province, South Africa

Background:

South Africa requires high-quality primary health care (PHC) to retain patients and optimize outcomes. While prior research has identified implementation challenges within the PHC system, there is less understanding of how providers define quality, their perceptions of barriers to providing quality care, and how they overcome these barriers. This study assesses provider views on quality at primary care clinics in a rural sub-district of Mpumalanga Province.

Methods:

We conducted in-depth interviews with providers in early 2019 on the value of quality metrics for providers and patients, what indicators they would use to assess clinic performance, and barriers and facilitators of delivering care. Interviews were conducted in Shangaan, audio-recorded, and translated into English. A deductive approach was used to develop a provisional coding schema, which was then refined using an inductive approach in response to patterns and themes emerging from the data.

Results:

Twenty-three providers were interviewed (83% female, 65% professional nurses). Providers did not give a single standard definition of quality care. Clinic structure and resources emerged as a key issue, as providers linked deficiencies in infrastructure and support to deficits in care delivery. Providers identified mitigating strategies including informal coordination across clinics to address medication and equipment shortages. Common across the providers’ discussion was poor communication between the district, PHC supervisors, and implementers at the facility level.

Conclusion:

Providers connected deficits in quality of care to inadequate infrastructure and insufficient support from district and provincial authorities; mitigating strategies across clinics could only partially address these deficits. The existence of a national quality measurement program was not broadly reflected in providers’ views on quality care. These findings underscore the need for effective district and national approaches to support individual facilities, accompanied by feedback methods designed with input from frontline service providers.

Factors affecting the implementation of HIV/AIDS prevention programs: A literature review

OBJECTIVE

The aim of this paper is to assess how male involvement and commitment from the government can affect the HIV/AIDS prevention programs.

METHOD

A literature review was conducted by using some databases to make a comprehensive search strategy, such as; CINAHL, International Bibliography of the Social Science (IBBS), and Anthropology Plus. Specific keywords were operated to gain specific information that will appropriate with the study.

RESULT

The strong commitment from the government becomes one of the important factors as well as the availability of funding. In the patriarchal country, male involvement will play a significant role in HIV/AIDS prevention programs.

CONCLUSION

Enhancing government and male involvement in HIV/AIDS prevention programs is important. It is also pivotal to seek other factors that may affect the implementation of HIV/AIDS prevention programs.

Mixed methods process evaluation of pilot implementation of the African Federation for Emergency Medicine trauma data project protocol in Ethiopia

Introduction

The African Federation for Emergency Medicine Trauma Data Project (AFEM-TDP) has created a protocol for trauma data collection in resource-limited settings using a clinical chart with embedded standardized data points that facilitates a systematic approach to injured patients. We performed a process evaluation of the protocol’s implementation at Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia to provide insights for adapting the protocol to our setting.

Methods

During the pilot implementation period, the quality of collected data was assessed. Structured key informant interviews about participant experiences and perceptions of the protocol implementation were then conducted. Interviews were analysed using a SWOT model.

Results

During pilot data collection, the overall capture rate was 21%. Variables collected with high frequency included demographics, vital signs and ED diagnosis, while mechanism of injury and ED disposition were often missed. Key informant interviews identified Strengths, Weaknesses, Opportunities and Threats to the protocol. Strengths included improved patient care, enhanced training for junior providers and facilitated data collection. Weaknesses included inadequate supervision and challenges relating to the physical size of the form, which resulted in missing data. Opportunities included retrospective research and quality improvement work. Threats included perceived lack of a local champion, poor buy-in from other hospital departments and need for ongoing financial support.

Conclusion

A mixed methods process evaluation is an invaluable tool when implementing novel data collection protocols, especially in resource-limited settings. We determined early successes and challenges of the implementation of the AFEM-TDP protocol and generated strategies to adapt the protocol to better suit our setting. Lessons from this process evaluation may be informative for other researchers designing and implementing similar data collection protocols.

A qualitative study exploring infant feeding decision-making between birth and 6 months among HIV-positive mothers

Despite efforts to support breastfeeding for HIV-positive mothers in South Africa, being HIV-positive remains a barrier to initiating and sustaining breastfeeding. The aim was to explore decision-making about infant feeding practices among HIV-positive mothers in a rural and urban settings in KwaZulu-Natal, South Africa. HIV-positive pregnant women were purposively sampled from one antenatal clinic in each setting. A qualitative longitudinal cohort design was employed, with monthly in-depth interviews conducted over 6 months postdelivery. Data were analysed using framework analysis. We report findings from 11 HIV-positive women within a larger cohort. Participants were aged between 15 and 41 years and were all on antiretroviral therapy. Before delivery, nine mothers intended to exclusively breastfeed (EBF) for 6 months, and two intended to exclusively formula feed (EFF). Three mothers successfully EBF for 6 months, whereas four had stopped breastfeeding, and two were mixed breastfeeding by 6 months. Mothers reported receiving strong advice from health workers (HWs) to EBF and made decisions based primarily on HWs advice, resisting contrary pressure from family or friends. The main motivation for EBF was to protect the child from HIV acquisition, but sometimes fear of mixed feeding led to mothers stopping breastfeeding entirely. Infant feeding messages from HWs advice were frequently inadequate and out of date, and failed to address mothers' challenges. Minimal support was provided for EFF. In conclusion, HWs play a pivotal role in providing infant feeding support to HIV infected mothers, but need regular updates to ensure if advice is correct and appropriate.

Combining Theory-Driven Evaluation and Causal Loop Diagramming for Opening the 'Black Box' of an Intervention in the Health Sector: A Case of Performance-Based Financing in Western Uganda

Increased attention on "complexity" in health systems evaluation has resulted in many different methodological responses. Theory-driven evaluations and systems thinking are two such responses that aim for better understanding of the mechanisms underlying given outcomes. Here, we studied the implementation of a performance-based financing intervention by the Belgian Technical Cooperation in Western Uganda to illustrate a methodological strategy of combining these two approaches. We utilized a systems dynamics tool called causal loop diagramming (CLD) to generate hypotheses feeding into a theory-driven evaluation. Semi-structured interviews were conducted with 30 health workers from two districts (Kasese and Kyenjojo) and with 16 key informants. After CLD, we identified three relevant hypotheses: "success to the successful", "growth and underinvestment", and "supervision conundrum". The first hypothesis leads to increasing improvements in performance, as better performance leads to more incentives, which in turn leads to better performance. The latter two hypotheses point to potential bottlenecks. Thus, the proposed methodological strategy was a useful tool for identifying hypotheses that can inform a theory-driven evaluation. The hypotheses are represented in a comprehensible way while highlighting the underlying assumptions, and are more easily falsifiable than hypotheses identified without using CLD.

Closing the gap in HIV prevention and care for children: early insights from a model that links communities and health care facilities in Uganda

Inequities in access to HIV prevention and treatment for children remain a global challenge and a black spot to effective HIV prevention and response especially in many HIV endemic countries like Uganda. In Uganda while about 51% of the adults living with HIV are on antiretrovirals, only 39% of the children aged 0-14 years accessed the needed HIV care in 2014. In this article, it is argued that much focus on health system interventions with little regard to bridging the gap between health facilities, where much of the care is provided, and the communities, where children are conceived, born and cared for, contributes to and sustains this inequality. Investments need to be made in building and implementing models that create and enhance linkages between communities and health care facilities. Success factors from the Towards an AIDS Free Generation in Uganda project model in creating these linkages are bringing all actors together in one approach, building on existing community structures and enabling community health workers to be the linking pin between communities and facilities. Only with models like this, full elimination of mother-to-child transmission and paediatric HIV care coverage (0-14 years) can be reached in Uganda and other HIV endemic countries.

Challenges encountered in providing integrated HIV, antenatal and postnatal care services: a case study of Katakwi and Mubende districts in Uganda

Background

Integration of sexual and reproductive health (SRH), HIV/AIDS and maternal health (MH) services is a critical strategy to confront the HIV/AIDS epidemic, high maternal mortality and the unmet need for contraception. In 2011 the AIDS Information Centre (AIC) in partnership with the Ministry of Health implemented SRH, HIV/AIDS and MH integration services in the districts of Katakwi and Mubende in Uganda. This paper documents challenges encountered in providing these integrated services in the two districts.

Methods

This was a cross-sectional qualitative study conducted in Mubende and Katakwi districts in Uganda. Data were collected using 10 focus group discussions with 89 women attending ANC and postnatal care and 21 key informant interviews with district managers and health workers who were involved in the integrated service delivery. Content thematic approach was used for data analysis.

Results

The study findings indicate that various challenges were encountered in integrating HIV, ANC and PNC services. Major challenges included inadequate staff, gaps in knowledge of service providers especially with regard to provision of long-term family planning, limited space, shortage of critical supplies such as HIV test kits, drugs and gloves.

Conclusion

These findings indicate that the delivery of integrated HIV, SRH and MH services is hampered greatly by health system challenges and depict the need for additional staffing in health facilities, capacity building of health workers and health managers as well as ensuring sufficient supplies to health facilities for smooth implementation of integrated SRH, HIV and MH services.

A comprehensive review of the barriers and promoters health workers experience in delivering prevention of vertical transmission of HIV services in sub-Saharan Africa

Despite significant biomedical and policy advances, 199,000 infants and young children in sub-Saharan Africa (SSA) became infected with HIV in 2013, indicating challenges to implementation of these advances. To understand the nature of these challenges, we sought to (1) characterize the barriers and facilitators that health workers encountered delivering prevention of vertical transmission of HIV (PVT) services in SSA and (2) evaluate the use of theory to guide PVT service delivery. The PubMed and CINAHL databases were searched using keywords barriers, facilitators, HIV, prevention of vertical transmission of HIV, health workers, and their synonyms to identify relevant studies. Barriers and facilitators were coded at ecological levels according to the Determinants of Performance framework. Factors in this framework were then classified as affecting motivation, opportunity, or ability, per the Motivation-Opportunity-Ability (MOA) framework in order to evaluate domains of health worker performance within each ecological level. We found that the most frequently reported challenges occurred within the health facility level and spanned all three MOA domains. Barriers reported in 30% or more of studies from most proximal to distal included those affecting health worker motivation (stress, burnout, depression), patient opportunity (stigma), work opportunity (poor referral systems), health facility opportunity (overburdened workload, lack of supplies), and health facility ability (inadequate PVT training, inconsistent breastfeeding messages). Facilitators were reported in lower frequencies than barriers and tended to be resolutions to challenges (e.g., quality supervision, consistent supplies) or responses to an intervention (e.g., record systems and infrastructure improvements). The majority of studies did not use theory to guide study design or implementation. Interventions addressing health workers' multiple ecological levels of interactions, particularly the health facility, hold promise for far-reaching impact as distal factors influence more proximal factors. Incorporating theory that considers factors beyond the health worker will strengthen endeavors to mitigate barriers to PVT service delivery.

Beyond early infant diagnosis: case finding strategies for identification of HIV-infected infants and children

There are 3.4 million children infected with HIV worldwide, with up to 2.6 million eligible for treatment under current guidelines. However, roughly 70% of infected children are not receiving live-saving HIV care and treatment. Strengthening case finding through improved diagnosis strategies, and actively linking identified HIV-infected children to care and treatment is essential to ensuring that these children benefit from the care and treatment available to them. Without attention or advocacy, the majority of these children will remain undiagnosed and die from complications of HIV. In this article, we summarize the challenges of identifying HIV-infected infants and children, review currently available evidence and guidance, describe promising new strategies for case finding, and make recommendations for future research and interventions to improve identification of HIV-infected infants and children.

High PMTCT program uptake and coverage of mothers, their partners, and babies in northern Uganda: achievements and lessons learned over 10 years of implementation (2002-2011)

BACKGROUND

The international nongovernmental organization "AVSI Foundation" has been actively supporting Uganda's Ministry of Health (MoH) prevention of mother-to-child HIV transmission (PMTCT) program since 2002 in 4 districts of the conflict-ridden Acholi subregion in Northern Uganda.

OBJECTIVE

This article presents data covering 10 years of MoH/AVSI PMTCT program activities in Northern Uganda.

METHODS

The program followed Uganda MoH PMTCT guidelines and aimed to be comprehensive, emphasizing social and medical care and support. Data were collected from 24 health facilities from January 2002 to December 2011. Trend analyses were carried out using Predictive Analytics SoftWare (PASW) Statistics 18.

RESULTS

Of the 140,658 women who newly attended antenatal care services from 2002 to 2011, 94.4% received HIV testing and counseling and 6.2% tested HIV-positive. HIV testing and counseling of male partners of tested pregnant women steadily increased from 5.9% in 2002 to 75.8% in 2011, compared with 15.5% in 2011 nationally. Overall, 79.0% of HIV-positive women were started on antiretroviral prophylaxis (69.4%) or triple antiretroviral therapy (9.6%), compared with 52% nationally in 2011. The proportion of HIV-positive women who delivered in health facilities significantly increased from 55.8% in 2004 to 81.1% in 2011 (no national data available). HIV prevalence among HIV-exposed infants tested at or below 18 months of age significantly decreased from 10.3% in 2004 to 5.0% in 2011.

CONCLUSIONS

Our results show how a comprehensive PMTCT program emphasizing social and community engagement alongside medical care and support can succeed in a remote setting with multiple challenges.

Comparative effectiveness of congregation- versus clinic-based approach to prevention of mother-to-child HIV transmission: study protocol for a cluster randomized controlled trial

Background

A total of 22 priority countries have been identified by the WHO that account for 90% of pregnant women living with HIV. Nigeria is one of only 4 countries among the 22 with an HIV testing rate for pregnant women of less than 20%. Currently, most pregnant women must access a healthcare facility (HF) to be screened and receive available prevention of mother-to-child HIV transmission (PMTCT) interventions. Finding new approaches to increase HIV testing among pregnant women is necessary to realize the WHO/ President's Emergency Plan for AIDS Relief (PEPFAR) goal of eliminating new pediatric infections by 2015.

Methods

This cluster randomized trial tests the comparative effectiveness of a congregation-based Healthy Beginning Initiative (HBI) versus a clinic-based approach on the rates of HIV testing and PMTCT completion among a cohort of church attending pregnant women. Recruitment occurs at the level of the churches and participants (in that order), while randomization occurs only at the church level. The trial is unblinded, and the churches are informed of their randomization group. Eligible participants, pregnant women attending study churches, are recruited during prayer sessions. HBI is delivered by trained community health nurses and church-based health advisors and provides free, integrated on-site laboratory tests (HIV plus hemoglobin, malaria, hepatitis B, sickle cell gene, syphilis) during a church-organized ‘baby shower.’ The baby shower includes refreshments, gifts exchange, and an educational game show testing participants’ knowledge of healthy pregnancy habits in addition to HIV acquisition modes, and effective PMTCT interventions. Baby receptions provide a contact point for follow-up after delivery. This approach was designed to reduce barriers to screening including knowledge, access, cost and stigma. The primary aim is to evaluate the effect of HBI on the HIV testing rate among pregnant women. The secondary aims are to evaluate the effect of HBI on the rate of HIV testing among male partners of pregnant women and the rate of PMTCT completion among HIV-infected pregnant women.

Discussion

Results of this study will provide further understanding of the most effective strategies for increasing HIV testing among pregnant women in hard-to-reach communities.

Trial Registration

Clinicaltrials.gov, NCT01795261

Infant feeding in the context of HIV: a qualitative study of health care workers' knowledge of recommended infant feeding options in Papua New Guinea

Background

Interventions to prevent mother to child transmission of human immunodeficiency virus (HIV) during childbirth and breastfeeding can reduce HIV infections in infants to less than 5% in low and middle income countries. The World Health Organization (WHO) recommends all mothers, regardless of their HIV status, practice exclusive breastfeeding for the first six months of an infant’s life. In line with these recommendations and to protect, promote and support breastfeeding, in 2009 the PNG National Department of Health revised their National HIV infant feeding guidelines, reinforcing the WHO recommendation of exclusive breastfeeding for the first six months followed by the introduction of other food and fluids, while continuing breastfeeding.

The overall aim of this paper is to explore health care workers’ knowledge regarding infant feeding options in PNG, specifically as they relate to HIV exposed infants.

Methods

As part of a study investigating women’s and men’s experiences of prevention of mother to child transmission (PMTCT) services in two sites in PNG, 28 key informant interviews were undertaken. This paper addresses one theme that emerged from thematic data analysis: Health care workers’ knowledge regarding infant feeding options, specifically how this knowledge reflects the Papua New Guinea National HIV Care and Treatment Guidelines on HIV and infant feeding (2009).

Results

Most informants mentioned exclusive breastfeeding, the majority of whom reflected the most up-to-date National Guidelines of exclusive breastfeeding for six months. The importance of breastfeeding continuing beyond this time, along with the introduction of food and fluids was less well understood. The most senior people involved in PMTCT were the informants who most accurately reflected the national guidelines of continuing breastfeeding after six months.

Conclusion

Providing advice on optimal infant feeding in resource poor settings is problematic, especially in relation to HIV transmission. Findings from our study reflect those found elsewhere in identifying that key health care workers are not aware of up-to-date information relating to infant feeding, especially within the context of HIV. Greater emphasis needs to be placed on ensuring the most recent feeding guidelines are disseminated and implemented in clinical practice in PNG.

'What mother wouldn't want to save her baby?' HIV testing and counselling practices in a rural Ugandan antenatal clinic

Drawing on an exploratory qualitative case study investigating everyday practices within an antenatal clinic in rural Uganda, this paper investigates the dynamics of consent and counselling within a prevention of mother-to-child HIV transmission (PMTCT) programme, from the perspectives of various health professionals involved at different stages of the PMTCT trajectory. The paper contributes to the existing literature by focusing not on clients' views but, rather, by elucidating how different cadres of health workers view and practice the human rights principles of informed consent and opting out, that are reflected in Uganda's HIV testing policies. By investigating the roles and responsibilities of community counsellors, post-test counsellors, and midwives, we illustrate how the practice of counselling in PMTCT is influenced by two hegemonic discourses: the health of a child should be protected, and the health worker knows best. As a result, a directive form of counselling in PMTCT settings, with its focus on the health of the baby, silences women's right to opt out of HIV tests.