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Urrio RF, Lyatuu GW, Sando D, Mahande MJ, Philipo E, Naburi H, Lyaruu P, Kimonge A, Mayogu K, Simba B, Kibao AM, Msangi M, Zeebari Z, Biberfeld G, Ekström AM, Kilewo C, Kågesten AE. Long-term retention on antiretroviral treatment after enrolment in prevention of vertical HIV transmission services: a prospective cohort study in Dar es Salaam, Tanzania. J Int AIDS Soc 2024; 27:e26186. [PMID: 38332522 PMCID: PMC10853596 DOI: 10.1002/jia2.26186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 10/09/2023] [Indexed: 02/10/2024] Open
Abstract
INTRODUCTION To prevent vertical HIV transmission and ensure healthy mothers and children, pregnant women with HIV must remain on antiretroviral treatment (ART) for life. However, motivation to remain on ART may decline beyond the standard 2-year breastfeeding/postpartum period. We assessed attrition and retention in ART care among women with HIV up to 6 years since enrolment in vertical transmission prevention services in Dar es Salaam, Tanzania. METHODS A prospective cohort of 22,631 pregnant women with HIV were enrolled in vertical transmission prevention services between January 2015 and December 2017 in routine healthcare settings and followed-up to July 2021. Kaplan-Meier was used to estimate time to ART attrition (died, stopped ART or was lost to follow-up [no show ≥90 days since scheduled appointment]) and the proportion retained in care. Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR) of ART attrition in relation to predictors. RESULTS Participants were followed-up to 6 years for a median of 3 years (IQR: 0.1-4). The overall ART attrition rate was 13.8 per 100 person-years (95% CI: 13.5-14.1), highest in the first year of enrolment at 27.1 (26.3-27.9), thereafter declined to 9.5 (8.9-10.1) in year 3 and 2.7 (2.1-3.5) in year 6. The proportion of women retained in care were 78%, 69%, 63%, 60%, 57% and 56% at 1, 2, 3, 4, 5 and 6 years, respectively. ART attrition was higher in young women aged <20 years (aHR 1.63, 95% CI: 1.38-1.92) as compared to 30-39 year-olds and women enrolled late in the third versus first trimester (aHR 1.29, 95% CI: 1.16-1.44). In contrast, attrition was lower in older women ≥40 years, women who initiated ART before versus during the index pregnancy and women attending higher-level health facilities. CONCLUSIONS ART attrition among women with HIV remains highest in the first year of enrolment in vertical transmission prevention services and declines markedly following a transition to chronic HIV care. Targeted interventions to improve ART continuity among women with HIV during and beyond prevention of vertical transmission are vital to ending paediatric HIV and keeping women and children alive and healthy.
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Affiliation(s)
- Roseline Faustine Urrio
- Management and Development for HealthDar es SalaamTanzania
- Department of Obstetrics and GynacologyMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Goodluck Willey Lyatuu
- Management and Development for HealthDar es SalaamTanzania
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - David Sando
- Management and Development for HealthDar es SalaamTanzania
| | | | | | - Helga Naburi
- Department of Pediatric and Child HealthMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Peter Lyaruu
- Management and Development for HealthDar es SalaamTanzania
| | - Amanda Kimonge
- Management and Development for HealthDar es SalaamTanzania
| | - Kasasi Mayogu
- Management and Development for HealthDar es SalaamTanzania
| | - Brenda Simba
- Management and Development for HealthDar es SalaamTanzania
| | | | | | - Zangin Zeebari
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - Gunnel Biberfeld
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - Anna Mia Ekström
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
- Department of Infectious Disease/VenhälsanSouth General HospitalStockholmSweden
| | - Charles Kilewo
- Department of Obstetrics and GynacologyMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Anna E. Kågesten
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
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Sliefert M, Maloba M, Wexler C, Were F, Mbithi Y, Mugendi G, Maliski E, Nicolay Z, Thomas G, Kale S, Maosa N, Finocchario-Kessler S. Challenges with pediatric antiretroviral therapy administration: Qualitative perspectives from caregivers and HIV providers in Kenya. PLoS One 2024; 19:e0296713. [PMID: 38194419 PMCID: PMC10775971 DOI: 10.1371/journal.pone.0296713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 12/15/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Current formulations of pediatric antiretroviral therapy (ART) for children with HIV present significant barriers to adherence, leading to drug resistance, ART ineffectiveness, and preventable child morbidity and mortality. Understanding these challenges and how they contribute to suboptimal adherence is an important step in improving outcomes. This qualitative study describes how regimen-related challenges create barriers to adherence and impact families. METHODS We conducted key informant interviews (KIIs) with 30 healthcare providers and 9 focus group discussions (FGDs) with a total of 72 caregivers, across three public hospitals in Siaya and Mombasa Kenya. The KIIs and FGDs were audio recorded, translated, and transcribed verbatim. The transcripts were hand coded based on emergent and a-priori themes. RESULTS Caregivers discussed major regimen-related challenges to adherence included poor palatability of current formulations, complex preparation, and administration (including measuring, crushing, dissolving, mixing), complex drug storage, and frequent refill appointments and how these regimen-related challenges contributed to individual and intrapersonal barriers to adherence. Caregivers discussed how poor taste led to child anxiety, refusal of medications, and the need for caregivers to use bribes or threats during administration. Complex preparation led to concerns and challenges about maintaining privacy and confidentiality, especially during times of travel. Providers corroborated this patient experience and described how these challenges with administration led to poor infant outcomes, including high viral load and preventable morbidity. Providers discussed how the frequency of refills could range from every 2 weeks to every 3 months, depending on the patient. Caregivers discussed how these refill frequencies interrupted work and school schedules, risked unwanted disclosure to peers, required use of financial resources for travel, and ultimately were a challenge to adherence. CONCLUSION These findings highlight the need for improved formulations for pediatric ART to ease the daily burden on caregivers and children to increase adherence, improve child health, and overall quality of life of families.
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Affiliation(s)
- Michala Sliefert
- University of Kansas Medical Center, Kansas City, KS, United States of America
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Catherine Wexler
- University of Kansas Medical Center, Kansas City, KS, United States of America
| | | | | | | | - Edward Maliski
- Oak Therapeutics, Lawrence, KS, United States of America
| | | | - Gregory Thomas
- University of Kansas, Lawrence, KS, United States of America
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Maingi M, Stark AH, Iron-Segev S. The impact of Option B+ on mother-to-child transmission of HIV in Africa: A systematic review. Trop Med Int Health 2022; 27:553-563. [PMID: 35477948 PMCID: PMC9328372 DOI: 10.1111/tmi.13756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Objective In 2015, the WHO released new guidelines to reduce mother‐to‐child transmission (MTCT) of HIV. The recommendations, known as Option B+, included initiation of lifelong highly active antiretroviral therapy regardless of CD4 count for all HIV‐positive pregnant and breastfeeding mothers. For infants, exclusive breastfeeding for 6 months and antiviral therapy were sanctioned. Targets of <5% transmission in breastfeeding populations and <2% in non‐breastfeeding populations were set. This review evaluated the impact of Option B+ on MTCT in African countries. Methods Using the PRISMA guidelines, a systematic search of PubMed and Google Scholar databases was conducted to identify relevant studies published between 2015 and 2021. All studies meeting inclusion criteria were evaluated. Results Of the 687 references screened, 22 studies from 11 countries (Cameroon, Ethiopia, Lesotho, Malawi, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe) met inclusion criteria. Six studies reported MTCT rates of <2%, 16 studies reported rates of 2–5% and two studies (Uganda and Zambia) reported 6% or more. Rates varied within the same study at different time points postpartum and amongst studies from the same country. Overall, reported MTCT rates appear to be close to WHO targets. However, diverse study designs, selection bias, extensive loss to follow‐up and undocumented adherence rates to Option B+ protocols may significantly underestimate MTCT rates of HIV in Africa. Conclusions Standardised protocols for impact evaluation must be established to provide evidenced‐based data on the efficacy of Option B+ in Africa.
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Affiliation(s)
- Mildred Maingi
- The Hebrew University of Jerusalem, Robert H. Smith Faculty of Agriculture, Food and Environment, Rehovot, Israel
| | - Aliza Hannah Stark
- The Hebrew University of Jerusalem, Robert H. Smith Faculty of Agriculture, Food and Environment, Rehovot, Israel
| | - Sharon Iron-Segev
- The Hebrew University of Jerusalem, Robert H. Smith Faculty of Agriculture, Food and Environment, Rehovot, Israel.,School of Nutritional Sciences, Peres Academic Center, Rehovot, Israel
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Etoori D, Kabudula CW, Wringe A, Rice B, Renju J, Gomez-Olive FX, Reniers G. Investigating clinic transfers among HIV patients considered lost to follow-up to improve understanding of the HIV care cascade: Findings from a cohort study in rural north-eastern South Africa. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000296. [PMID: 36962304 PMCID: PMC10022370 DOI: 10.1371/journal.pgph.0000296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 05/02/2022] [Indexed: 11/18/2022]
Abstract
Investigating clinical transfers of HIV patients is important for accurate estimates of retention and informing interventions to support patients. We investigate transfers for adults reported as lost to follow-up (LTFU) from eight HIV care facilities in the Agincourt health and demographic surveillance system (HDSS), South Africa. Using linked clinic and HDSS records, outcomes of adults more than 90 days late for their last scheduled clinic visit were determined through clinic and routine tracing record reviews, HDSS data, and supplementary tracing. Factors associated with transferring to another clinic were determined through Cox regression models. Transfers were graphically and geospatially visualised. Transfers were more common for women, patients living further from the clinic, and patients with higher baseline CD4 cell counts. Transfers to clinics within the HDSS were more likely to be undocumented and were significantly more likely for women pregnant at ART initiation. Transfers outside the HDSS clustered around economic hubs. Patients transferring to health facilities within the HDSS may be shopping for better care, whereas those who transfer out of the HDSS may be migrating for work. Treatment programmes should facilitate transfer processes for patients, ensure continuity of care among those migrating, and improve tracking of undocumented transfers.
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Affiliation(s)
- David Etoori
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Chodziwadziwa Whiteson Kabudula
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Alison Wringe
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Brian Rice
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jenny Renju
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Francesc Xavier Gomez-Olive
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Georges Reniers
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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Mbatha TL, Dube A. HIV Positive Pregnant Mothers' Perceptions and Experiences Regarding the Prevention of Mother-to-Child Transmission, Option B+ Program. J Patient Exp 2021; 8:23743735211065272. [PMID: 34901413 PMCID: PMC8655469 DOI: 10.1177/23743735211065272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: eSwatini is a small population-sized sub-Sahara African country characterized by its highest human immunodeficiency virus (HIV) prevalence globally. The prevalence of HIV among pregnant women is above 40%. In the past decade, the Government of eSwatini has demonstrated a high level of commitment to virally suppress HIV spread among its population. This study explored the perceptions and experiences of HIV-positive pregnant mothers regarding the prevention of mother-to-child transmission (PMTCT) Option B+ program in order to discuss and address the gaps in the health system. Methods: Qualitative, exploratory, and descriptive research design was used. Data was collected through in-depth interviews and field notes. Data was gathered from all cases of HIV-positive pregnant mothers enrolled at a Public Health Unit. Results: Seventeen pregnant women aged between 18 and 40 years participated. Findings revealed that the Option B+ program was positively perceived as preventing HIV from mother-to-child. It boosts the immune system, deters opportunistic infections, and prolongs life. Knowledge and understanding of the program were displayed despite challenges such as discrimination and no support from families. Conclusion: PMTCT Option B+ intervention was found to be effective in reducing mother-to-child transmission of HIV. Gaps between women and men about HIV and antiretroviral therapy need to be addressed through target messaging and stigmatization discussions so that men are encouraged to disclose their HIV status. Improving access to antiretroviral and retention of women on treatment can further reduce vertical HIV infection transmission.
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Affiliation(s)
- Trusty L Mbatha
- Department of Nursing Sciences, Southern Africa Nazarene University, Manzini, Swaziland
| | - Adiele Dube
- Department of Nursing Sciences, Southern Africa Nazarene University, Manzini, Swaziland
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Getaneh T, Negesse A, Dessie G. Experiences and Reasons of Attrition from Option B+ Among Mothers Under Prevention of Mother to Child Transmission Program in Northwest Ethiopia: Qualitative Study. HIV AIDS (Auckl) 2021; 13:851-859. [PMID: 34483688 PMCID: PMC8409763 DOI: 10.2147/hiv.s314306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 08/14/2021] [Indexed: 11/23/2022] Open
Abstract
Background Human immunodeficiency virus-infected children share the highest risk of death compared with all other age groups, and more than 90% of this viral infection of children was accounted for by transmission from mother to infant. This rate can be prevented and reduced with implementation of option B+ effectively. However, unacceptably high lost follow-up of mothers highly affected the effectiveness of this program. In Ethiopia, only 71% of mothers were adherent on their follow-up. So, this study was aimed to understand the reasons and experiences of lost follow-up of mothers under the prevention of mother to child transmission (option B+) program in North West Ethiopia. Methods A qualitative study using a case study design was carried out using in-depth interviews among 20 mothers who had started the option B+ treatment protocol but discontinued their follow-up for more than two months, and 6 key informants and individuals who were engaged in management and control of human immunodeficiency virus at Woreda and Zonal level. An unstructured interview guide was used and translated into the local language. Study participants were selected using purposive sampling technique. After written consent was obtained, all study participants’ interviews were audio-recorded and analyzed using deductive content analysis. Results A total of 26 mothers participated in this study. Accordingly, the most frequently raised reasons were lack of formal education which affects income level, lack of disclosure, lack of partner and family support, absence of male involvement and stigma-discrimination. But, unavailability of option B+ regimens in the nearest health facility or long distance from health facility, discordance and lack of experienced professionals in terms of counseling during initiation were also essential reasons. Conclusion Educational and economic empowerment intervention (particularly for vulnerable households), promoting family support and male involvement, active counseling at initiation and during follow up and community level awareness improvement should be addressed to increase option B+ regimen adherence and retention.
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Affiliation(s)
- Temesgen Getaneh
- Department of Midwifery, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
- Correspondence: Temesgen Getaneh Email
| | - Ayenew Negesse
- Department of Human Nutrition and Food Sciences, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
- Center of Excellence in Human Nutrition, Food Science and Technology, Hawassa University, Hawassa, Ethiopia
| | - Getenet Dessie
- Department of Nursing, College of Medicine and Health Science, Bahr Dar University, Bahir Dar, Ethiopia
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Lusaka M, Crowley T. Administering human immunodeficiency virus post-exposure prophylaxis: challenges experienced by mothers in Lusaka, Zambia. South Afr J HIV Med 2021; 22:1183. [PMID: 33604065 PMCID: PMC7876968 DOI: 10.4102/sajhivmed.v22i1.1183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/16/2020] [Indexed: 11/24/2022] Open
Abstract
Background Mothers living with human immunodeficiency virus (HIV) should be guided to practise safe childbirth, provide appropriate infant feeding, return infants for repeat HIV testing and administer for the required period, protective antiretroviral (ARV) medication (post-exposure prophylaxis [PEP]) to their infants. Although several studies have explored challenges related to the prevention of mother-to-child transmission (PMTCT), no studies were found that focused specifically on the mother and PEP. Objectives To explore and understand the challenges experienced by mothers in Lusaka, Zambia, whilst providing their children with PEP. Methods This study utilised a qualitative methodology and a descriptive design. Fifteen semi-structured individual interviews were conducted with mothers who gave PEP to their infants. Study evaluation made use of Creswell’s six steps of data analysis. Results Women experienced numerous challenges. Challenges of an individual and social nature included ‘negative’ emotions, misconceptions and a lack of understanding of PEP. Post-exposure prophylaxis was sometimes burdensome and partner involvement often limited. Cultural, religious practices and stigma deterred some women from continuing PEP. Healthcare challenges included time-consuming appointments and protracted waiting periods. Clinic organisation was often inefficient and complicated by stock-outs of essential medication such as nevirapine. Healthcare workers were at times stigmatising towards mothers living with HIV and their infants. The counselling support provided by the healthcare workers was felt to be inadequate in the face of the burden of PEP. Conclusion Post-exposure prophylaxis as part of the PMTCT programme is key to eliminating mother-to-child transmission of HIV. Postnatal support for women administering PEP to their children can be enhanced through counselling that is person- and family-centred is culturally sensitive and offers differentiated services that include PEP, integrated mother-and-child healthcare and access to support groups.
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Affiliation(s)
- Mildred Lusaka
- Department of Nursing and Midwifery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Talitha Crowley
- Department of Nursing and Midwifery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Abstract
Human immunodeficiency virus (HIV) is one of the most serious pediatric infectious diseases, affecting around 3 million children and adolescents worldwide. Lifelong antiretroviral treatment (ART) provides multiple benefits including sustained virologic suppression, restoration and preservation of immune function, decreased morbidity and mortality, and improved quality of life. However, access to ART, particularly among neonates and young infants, continues to be challenging due to limited number of suitable formulations and limited access to pediatric ARV drug. Moreover, children and adolescents living with HIV may experience long-term HIV- and ART-associated comorbidities including cardiovascular, renal, neurological, and metabolic complications. We provide an overview of currently available formulations, dosing, and safety considerations for pediatric antiretroviral drugs by drug classes and according to the three age groups including neonates, children, and adolescents.
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Affiliation(s)
- Sahera Dirajlal-Fargo
- Pediatric Infectious Diseases, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Wei Li A Koay
- Department of Pediatrics, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA.,Division of Infectious Diseases, Children's National Medical Center, Washington, DC, USA
| | - Natella Rakhmanina
- Department of Pediatrics, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA.,Division of Infectious Diseases, Children's National Medical Center, Washington, DC, USA.,Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
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Kiwuwa-Muyingo S, Abongomera G, Mambule I, Senjovu D, Katabira E, Kityo C, Gibb DM, Ford D, Seeley J. Lessons for test and treat in an antiretroviral programme after decentralisation in Uganda: a retrospective analysis of outcomes in public healthcare facilities within the Lablite project. Int Health 2020; 12:429-443. [PMID: 31730168 DOI: 10.1093/inthealth/ihz090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 07/20/2019] [Accepted: 08/27/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND We describe the decentralisation of antiretroviral therapy (ART) alongside Option B+ roll-out in public healthcare facilities in the Lablite project in Uganda. Lessons learned will inform programmes now implementing universal test and treat (UTT). METHODS Routine data were retrospectively extracted from ART registers between October 2012 and March 2015 for all adults and children initiating ART at two primary care facilities (spokes) and their corresponding district hospitals (hubs) in northern and central Uganda. We describe ART initiation over time and retention and use of Cox models to explore risk factors for attrition due to mortality and loss to follow-up. Results from tracing of patients lost to follow-up were used to correct retention estimates. RESULTS Of 2100 ART initiations, 1125 were in the north, including 944 (84%) at the hub and 181 (16%) at the spokes; children comprised 95 (10%) initiations at the hubs and 14 (8%) at the spokes. Corresponding numbers were 642 (66%) at the hub and 333 (34%) at the spokes in the central region (77 [12%] and 22 [7%], respectively, in children). Children <3 y of age comprised the minority of initiations in children at all sites. Twenty-three percent of adult ART initiations at the north hub were Option B+ compared with 45% at the spokes (25% and 65%, respectively, in the central region). Proportions retained in care in the north hub at 6 and 12 mo were 92% (95% CI 90 to 93) and 89% (895% CI 7 to 91), respectively. Corresponding corrected estimates in the north spokes were 87% (95% CI 78 to 93) and 82% (95% CI 72 to 89), respectively. In the central hub, corrected estimates were 84% (95% CI 80 to 87) and 78% (95% CI 74 to 82), and were 89% (95% CI 77.9 to 95.1) and 83% (95% CI 64.1 to 92.9) at the spokes, respectively. Among adults newly initiating ART, being older was independently associated with a lower risk of attrition (adjusted hazard ratio [aHR] 0.93 per 5 y [95% CI 0.88 to 0.97]). Other independent risk factors included initiating with a tenofovir-based regimen vs zidovudine (aHR 0.60 [95% CI 0.46 to 0.77]), year of ART initiation (2013 aHR 1.55 [95% CI 1.21 to 1.97], ≥2014 aHR 1.41 [95% CI 1.06 to 1.87]) vs 2012, hub vs spoke (aHR 0.35 [95% CI 0.29 to 0.43]) and central vs north (aHR 2.28 [95% CI 1.86 to 2.81]). Independently, patient type was associated with retention. CONCLUSIONS After ART decentralisation, people living with human immunodeficiency virus (HIV) were willing to initiate ART in rural primary care facilities. Retention on ART was variable across facilities and attrition was higher among some groups, including younger adults and women initiating ART during pregnancy/breastfeeding. Interventions to support these groups are required to optimise benefits of expanded access to HIV services under UTT.
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Affiliation(s)
- S Kiwuwa-Muyingo
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, PO Box 49, Entebbe, Uganda
- African Population and Health Research Center, P.O. Box 10787-00100, Kitisuru, Nairobi, Kenya
| | - G Abongomera
- Joint Clinical Research Centre, PO Box 10005, Kampala, Uganda
- University of Zurich, Epidemiology, Biostatistics and Prevention Institute, CH 8001, Zurich, Switzerland
| | - I Mambule
- Infectious Diseases Institute, Makerere University, PO Box 22418, Kampala, Uganda
| | - D Senjovu
- Infectious Diseases Institute, Makerere University, PO Box 22418, Kampala, Uganda
| | - E Katabira
- Infectious Diseases Institute, Makerere University, PO Box 22418, Kampala, Uganda
| | - C Kityo
- Joint Clinical Research Centre, PO Box 10005, Kampala, Uganda
| | - D M Gibb
- Medical Research Council, Clinical Trials Unit at University College London, London WC1V 6LH, UK
| | - D Ford
- Medical Research Council, Clinical Trials Unit at University College London, London WC1V 6LH, UK
| | - J Seeley
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, PO Box 49, Entebbe, Uganda
- Global Health and Development Department, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
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10
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Kisigo GA, Ngocho JS, Knettel BA, Oshosen M, Mmbaga BT, Watt MH. "At home, no one knows": A qualitative study of retention challenges among women living with HIV in Tanzania. PLoS One 2020; 15:e0238232. [PMID: 32853233 PMCID: PMC7451655 DOI: 10.1371/journal.pone.0238232] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 08/12/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Despite the broad success of Prevention of Mother-to-Child Transmission of HIV (PMTCT) programs, HIV care engagement during the pregnancy and postpartum periods is suboptimal. This study explored the perspectives of women who experienced challenges engaging in PMTCT care, in order to better understand factors that contribute to poor retention and to identify opportunities to improve PMTCT services. METHODS We conducted in-depth interviews with 12 postpartum women to discuss their experiences with PMTCT care. We used data from a larger longitudinal cohort study conducted in five PMTCT clinics in Moshi, Tanzania to identify women with indicators of poor care engagement (i.e., medication non-adherence, inconsistent clinic attendance, or high viral load). Women who met one of these criteria were contacted by telephone and invited to complete an interview. Data were analyzed using applied thematic analysis. RESULTS We observed a common pathway that fear of stigma contributed to a lack of HIV disclosure and reduced social support for seeking HIV care. Women commonly distrusted the results of their initial HIV test and reported medication side effects after care initiation. Women also reported barriers in the health system, including difficult-to-navigate clinic transfer policies and a lack of privacy and confidentiality in service provision. When asked how care might be improved, women felt that improved counseling and follow-up, affirming patient-provider interactions, and peer treatment supporters would have a positive effect on care engagement. CONCLUSION In order to improve the impact of PMTCT programs, there is a need to implement active tracking and follow-up of patients, targeting individuals with evidence of poor care engagement. Tailored supportive intervention approaches may help patients to cope with both the perceived and actual impacts of HIV stigma, including navigating disclosures to loved ones and accessing social support. Fostering HIV acceptance is likely to facilitate commitment to long-term treatment.
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Affiliation(s)
- Godfrey A. Kisigo
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - James S. Ngocho
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Brandon A. Knettel
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Martha Oshosen
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- The University of Cape Town, Cape Town, South Africa
| | - Blandina T. Mmbaga
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Melissa H. Watt
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
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Kiplagat AB, Ngunu C, Oyugi E, Ransom J. Epidemiology of HIV Infection Among HIV-Exposed Infants, Nairobi County, Kenya, 2015. Infect Dis (Lond) 2020; 13:1178633720948863. [PMID: 32913392 PMCID: PMC7444106 DOI: 10.1177/1178633720948863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 05/13/2020] [Indexed: 11/16/2022] Open
Abstract
Objective To characterize human immunodeficiency virus (HIV)-positive infants among HIV-exposed infants (HEIs) in Nairobi County for public health action. Methods We conducted a retrospective review of records of HEIs' HIV polymerase chain reaction (PCR) results in Nairobi County in 2015, excluding confirmatory PCR-positive results. HIV-exposed infant registry data were entered into Microsoft Excel and descriptive and associative statistics were calculated with OpenEpi software. Results A total of 5802 HEI records were analyzed, with a median age of 4.5 (interquartile range, 8.5) months; 342 (5.9%) tested positive, 51% were female, and 4420 (76.2%) were seen at maternal and child health clinics. Standard highly active antiretroviral therapy intervention was given to 184 (60.3%) of the mothers of exposed infants, and 178 (53%) of the HIV-positive infants received active antiretroviral therapy. A total of 3464 (59.7%) HEIs had PCR done within the first 2 months, and 119 (3.4%) tested positive. The average turnaround time for PCR samples was 28 ± 22 days, and a total of 191 (3.3%) HIV-positive HEIs were exclusively breastfed for the first 6 months of life. Conclusion The recorded mother-to-child transmission (MTCT) rate of 5.9% in Nairobi County is lower than the 2015 national rate, which suggests the Nairobi prevention of mother-to-child transmission efforts are moderately effective. However, results from this study show that Kenya will struggle to meet the MTCT 2020 target rate of <5%.
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Affiliation(s)
- Anthony B Kiplagat
- Nairobi City-County Health Services, Nairobi, Kenya.,Field Epidemiology and Laboratory Training Program, Ministry of Health, Nairobi, Kenya
| | - Carol Ngunu
- Nairobi City-County Health Services, Nairobi, Kenya.,Field Epidemiology and Laboratory Training Program, Ministry of Health, Nairobi, Kenya
| | - Elvis Oyugi
- Field Epidemiology and Laboratory Training Program, Ministry of Health, Nairobi, Kenya
| | - James Ransom
- Field Epidemiology and Laboratory Training Program, Ministry of Health, Nairobi, Kenya.,Piret Partners Consulting, Washington, DC, USA
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Etoori D, Renju J, Reniers G, Ndhlovu V, Ndubane S, Makhubela P, Maritze M, Gomez-Olive FX, Wringe A. 'If the results are negative, they motivate us'. Experiences of early infant diagnosis of HIV and engagement in Option B. Glob Public Health 2020; 16:186-200. [PMID: 32673142 DOI: 10.1080/17441692.2020.1795220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Few studies have explored the relationship between early infant diagnosis (EID) of HIV and mothers' engagement in care under Option B+. We conducted in-depth interviews with 20 women who initiated antiretroviral therapy (ART) under Option B+ in rural South Africa to explore the interactions between EID and maternal care engagement. Drawing on practice theory, we identified themes relating to Option B+ care engagement and EID. Women's practice of engagement with HIV care shaped their decision-making around EID. Mothers who disengaged from care during pregnancy were less inclined to utilise EID as they lacked information about its availability and benefits. For some mothers, tensions between wanting to breastfeed and perceptions that it could facilitate transmission led to repeated utilisation of EID as reassurance that the child remained negative. Some mothers used their child's negative result as a proxy for their status, subsequently disengaging from care. For some participants, an HIV diagnosis of their infant and the subsequent double burden of treatment visits for themselves and their infant, contributed to their disengagement. Women's care-seeking practices for themselves and their infants work in a symbiotic ecosystem and should be viewed interdependently to tailor interventions to improve EID uptake and Option B+ care engagement.
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Affiliation(s)
- David Etoori
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jenny Renju
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Georges Reniers
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.,MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Violet Ndhlovu
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sherly Ndubane
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Princess Makhubela
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Meriam Maritze
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Francesc Xavier Gomez-Olive
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Demissie DB, Bulto GA, Mekuria WT, Dufera FN, Gamshe EN. <p>Evaluation of Antiretroviral Therapy Initiated Among Pregnant Women Under Option B+ by Viral Load and CD4 Count Outcomes in Selected Hospitals of West Shewa Zone, Oromia Region, Ethiopia</p>. HIV AIDS (Auckl) 2020; 12:127-134. [PMID: 32256122 PMCID: PMC7090176 DOI: 10.2147/hiv.s242320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/10/2020] [Indexed: 11/23/2022] Open
Abstract
Background Antiretroviral therapy (ART) is effective for the elimination of mother-to-child transmission (eMTCT) of human immunodeficiency virus (HIV) infection, reducing infant mortality and ensuring maternal virologic suppression, while pregnant women require test and treat under Option B+ programs. Therefore, the study aimed to assess the evaluation of antiretroviral therapy initiated among pregnant women under Option B+ by viral load and CD4 count outcomes in selected hospitals of West Shewa Zone, Oromia Region, Ethiopia. Methods Hospital-based cross-sectional study design was employed to conduct the study at randomly selected hospitals providing Option B+ services with routine viral load assessment by Oromia Regional Laboratory (ORL) from January 2016 to January 2017. Bivariate and multivariable logistic regression analyses were conducted to determine factors affecting the time to ART initiation following an HIV test and logistic regression was used to determine the correlation between time and treatment outcomes. Results The viral load suppression (VL <1000 copies/mL) was achieved in 31% and 58.7% of patients who were on ART treatment for ≤37 months and longer than 38 months, respectively. It was identified that the mean viral load and CD4 count were 197.27 and 629.17, respectively, while 85.3% of the clients had their CD4 count increased from the baseline data. The study revealed that level of ART adherence, completion of full doses, compliance on appointments, duration of the ART uptake and baseline CD4 count were independent predictors of viral load suppression for women started on option B+ and continued on lifelong ART. And this study also revealed that gestational age at ART start, maternal age in years and adherence on medication were independently associated with CD4 response among HIV pregnant women initiated for lifelong ART. Conclusion The study results demonstrated that for 89.7% of study respondents, viral load was suppressed of which 80.3% were undetectable (VL= 0 copies/ml3 and 85.3% had increased CD4 count). This study determined the factors associated with viral load suppression and CD4 count improvement. Therefore, these factors should be emphatically considered during Option B+ program development and training to ensure CD4 count improvement and viral load suppression achievements.
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Affiliation(s)
- Dereje Bayissa Demissie
- Department of Neonatal Nursing, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
- Correspondence: Dereje Bayissa Demissie Email
| | - Gizachew Abdissa Bulto
- Department of Midwifery, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopia
| | - Wagi Tosisa Mekuria
- Department of Medical Laboratory Sciences, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopia
| | - Fikru Negassa Dufera
- Department of Public Health, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopa
| | - Eriste Nigussa Gamshe
- Department of Neonatal Nursing, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
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Slow Acceptance of Universal Antiretroviral Therapy (ART) Among Mothers Enrolled in IMPAACT PROMISE Studies Across the Globe. AIDS Behav 2019; 23:2522-2531. [PMID: 31399793 PMCID: PMC6766470 DOI: 10.1007/s10461-019-02624-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
Abstract
The PROMISE trial enrolled asymptomatic HIV-infected pregnant and postpartum women not eligible for antiretroviral treatment (ART) per local guidelines and randomly assigned proven antiretroviral strategies to assess relative efficacy for perinatal prevention plus maternal/infant safety and maternal health. The START study subsequently demonstrated clear benefit in initiating ART regardless of CD4 count. Active PROMISE participants were informed of results and women not receiving ART were strongly recommended to immediately initiate treatment to optimize their own health. We recorded their decision and the primary reason given for accepting or rejecting the universal ART offer after receiving the START information. One-third of participants did not initiate ART after the initial session, wanting more time to consider. Six sessions were required to attain 95% uptake. The slow uptake of universal ART highlights the need to prepare individuals and sensitize communities regarding the personal and population benefits of the "Treat All" strategy.
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Why did I stop? And why did I restart? Perspectives of women lost to follow-up in option B+ HIV care in Dar es Salaam, Tanzania. BMC Public Health 2019; 19:1172. [PMID: 31455306 PMCID: PMC6712622 DOI: 10.1186/s12889-019-7518-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 08/19/2019] [Indexed: 11/13/2022] Open
Abstract
Background Despite an increased uptake of option B+ treatment among HIV- positive pregnant and breastfeeding women, retaining these women in care is still a major challenge. Previous studies have identified factors associated with loss to follow-up (LTFU) in HIV care, however, the perspectives from HIV-positive pregnant and breastfeeding women regarding their LTFU in option B+ needs further exploration. We explored reasons for LTFU and motivation to resume treatment among HIV-positive women initiated in option B+ in an Urban setting. Methods A descriptive qualitative study was conducted at three public care and treatment clinics (CTC) (Buguruni health center, Sinza hospital, and Mbagala Rangitatu health center) in Dar es Salaam, Tanzania between February and May 2017. In-depth interviews were conducted with 30 HIV-positive pregnant and breastfeeding women who were lost to follow up in the option B+ regimen. Analysis of data followed content analysis that was performed using NVivo 10 computer-assisted qualitative data analysis software. Results Eleven women were lost to follow-up and did not resume Option B+, while 19 had resumed treatment. The study indicated a struggle with long term disease amongst HIV-positive pregnant and breastfeeding women initiated in option B+ treatment. The reported reasons contributing to LTFU among these women appeared in three categories. The contribution of LTFU in the first category namely health-related factors included medication side effects and lack of disease symptoms. The second category highlighted the contribution of psychological factors such as loss of hope, fear of medication side effects and HIV-related stigma. The third category underscored the influence of socio-economic statuses such as financial constraints, lack of partner support, family conflicts, non-disclosure of HIV-positive status, and religious beliefs. Motivators to resume treatment after LTFU included support from health care providers and family members, a desire to protect the unborn child from HIV-infection and a need to maintain a healthy status. Conclusion The study has highlighted the reasons for LTFU and motivation to resume treatment among women initiated in Option B+. Our results provide further evidence on the need for future interventions to focus on these factors in order to improve retention in life-long treatment.
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Wang X, Guo G, Zheng J, Lu L. Cost-effectiveness of option B+ in prevention of mother-to-child transmission of HIV in Yunnan Province, China. BMC Infect Dis 2019; 19:517. [PMID: 31185927 PMCID: PMC6560771 DOI: 10.1186/s12879-019-3976-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 04/11/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Although Option B+ may be more costly than Options B, it may provide additional health benefits that are currently unclear in Yunnan province. We created deterministic models to estimate the cost-effectiveness of Option B+. METHODS Data were used in two deterministic models simulating a cohort of 2000 HIV+ pregnant women. A decision tree model simulated the number of averted infants infections and QALY acquired for infants in the PMTCT period for Options B and B+. The minimum cost was calculated. A Markov decision model simulated the number of maternal life year gained and serodiscordant partner infections averted in the ten years after PMTCT for Option B or B+. ICER per life year gained was calculated. Deterministic sensitivity analyses were conducted. RESULTS If fully implemented, Option B and Option B+ averted 1016.85 infections and acquired 588,01.02 QALYs.The cost of Option B was US$1,229,338.47, the cost of Option B+ was 1,176,128.63. However, when Options B and B+ were compared over ten years, Option B+ not only improved mothers'ten-year survival from 69.7 to 89.2%, saving more than 3890 life-years, but also averted 3068 HIV infections between serodiscordant partners. Option B+ yielded a favourable ICER of $32.99per QALY acquired in infants and $5149per life year gained in mothers. A 1% MTCT rate, a 90% coverage rate and a 20-year horizon could decrease the ICER per QALY acquired in children and LY gained in mothers. CONCLUSIONS Option B+ is a cost-effective treatment for comprehensive HIV prevention for infants and serodiscordant partners and life-long treatment for mothers in Yunnan province, China. Option B+ could be implemented in Yunnan province, especially as the goals of elimination mother-to-child transmission of HIV and "90-90-90" achieved, Option B+ would be more attractive.
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Affiliation(s)
- Xiaowen Wang
- Yunnan Center for Disease Control and Prevention, No 158, Dongsi Street, Xishan District, Kunming, Yunnan Province China
- Kunming Medical University, No. 1168, west Chunrong Street, Chenggong district, Kunming, Yunnan Province China
| | - Guangping Guo
- Yunnan Maternal and Child Health Care Hospital, No. 200, Gulou Street, Wuhua District, Kunming, Yunnan Province China
| | - Jiarui Zheng
- Yunnan Maternal and Child Health Care Hospital, No. 200, Gulou Street, Wuhua District, Kunming, Yunnan Province China
| | - Lin Lu
- Kunming Medical University, No. 1168, west Chunrong Street, Chenggong district, Kunming, Yunnan Province China
- Health Commission of Yunnan Province, No. 309, Guomao Street, Kunming, Yunnan Province China
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Nyati-Jokomo Z, Chitsike I, Mbizvo E, January J. 'If nurses were in our shoes would they breastfeed their own babies?' A qualitative inquiry on challenges faced by breastfeeding mothers on the PMTCT programme in a rural community in Zimbabwe. BMC Pregnancy Childbirth 2019; 19:191. [PMID: 31146725 PMCID: PMC6543664 DOI: 10.1186/s12884-019-2336-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 05/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Prevention of Mother to Child Transmission (PMTCT) of HIV programme in Zimbabwe has had remarkable success despite the country's economic challenges. The aim of this study was to explore the challenges faced by breastfeeding mothers on the PMTCT programme. METHOD Narratives from 15 women (age range 19-35 years) were collected at two rural health facilities in Zimbabwe through in-depth interviews over a period of 6 months. Thematic analysis was used to describe breastfeeding mothers' experiences and challenges of being on the PMTCT programme. RESULTS The findings suggest that breastfeeding women on the PMTCT programme face challenges that include internal, external and institutional stigma and discrimination. Women reported a sense of powerlessness in decision making on following through with the PMTCT programme and were ambivalent regarding disclosure of their HIV status to their partners and significant others. CONCLUSION HIV and AIDS programmes should pay attention to women's readiness for interventions. There is need to understand women's life experiences to ensure informed and targeted programming for PMTCT.
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Affiliation(s)
- Zibusiso Nyati-Jokomo
- Department of Community Medicine, College of Health Sciences, University of Zimbabwe, PO Box A178, Avondale, Harare, Zimbabwe
| | - Inam Chitsike
- Department of Paediatrics and Child Health, University of Zimbabwe, Harare, Zimbabwe
| | - Elizabeth Mbizvo
- Department of Community Medicine, College of Health Sciences, University of Zimbabwe, PO Box A178, Avondale, Harare, Zimbabwe.
| | - James January
- Department of Community Medicine, College of Health Sciences, University of Zimbabwe, PO Box A178, Avondale, Harare, Zimbabwe
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Horter S, Wringe A, Thabede Z, Dlamini V, Kerschberger B, Pasipamire M, Lukhele N, Rusch B, Seeley J. "Is it making any difference?" A qualitative study examining the treatment-taking experiences of asymptomatic people living with HIV in the context of Treat-all in Eswatini. J Int AIDS Soc 2019; 22:e25220. [PMID: 30697970 PMCID: PMC6351702 DOI: 10.1002/jia2.25220] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/26/2018] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Treat-all is being implemented in several African settings, in accordance with 2015 World Health Organisation guidelines. The factors known to undermine adherence to antiretroviral therapy (ART) may change in the context of Treat-all, where people living with HIV (PLHIV) increasingly initiate ART at earlier, asymptomatic stages of disease, soon after diagnosis. This paper aimed to examine the asymptomatic PLHIV's experiences engaging with early ART initiation under the Treat-all policy, including how they navigate treatment-taking over the longer term. METHODS A longitudinal qualitative study was conducted within a Médecins Sans Frontières/Ministry of Health Treat-all pilot in Shiselweni, southern Eswatini. The Treat-all pilot began in October 2014, adopted into national policy in October 2016. Participants were recruited purposively to include newly diagnosed, clinically asymptomatic PLHIV with a range of treatment-taking experiences, and healthcare workers (HCW) with various roles. This analysis drew upon a sub-sample of 17 PLHIV who had been on ART for at least 12 months, with mean 20 months on ART at first interview, and who undertook three interviews each. Additionally, 20 HCWs were interviewed once. Interviews were conducted from August 2016 to September 2017. Data were analysed thematically using coding, drawing upon principles of grounded theory, and aided by Nvivo 11. RESULTS It was important for PLHIV to perceive the need for treatment, and to have evidence of its effectiveness to motivate their treatment-taking, thereby supporting engagement with care. For some, coming to terms with a HIV diagnosis or re-interpreting past illnesses as signs of HIV could point to the need for ART to prevent health deterioration and prolong life. However, others doubted the accuracy of an HIV diagnosis and the need for treatment in the absence of symptoms or signs of ill health, with some experimenting with treatment-taking as a means of seeking evidence of their need for treatment and its effect. Viral load monitoring appeared important in offering a view of the effect of treatment on the level of the virus, thereby motivating continued treatment-taking. CONCLUSIONS These findings highlight the importance of PLHIV perceiving need for treatment and having evidence of the difference that ART is making to them for motivating treatment-taking. Patient support should be adapted to address these concerns, and viral load monitoring made routinely available within Treat-all care, with communication of suppressed results emphasized to patients.
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Affiliation(s)
- Shona Horter
- Médecins Sans FrontièresNhlanganoEswatini
- London School of Hygiene and Tropical MedicineLondonUK
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Erekaha SC, Cornelius LJ, Bessaha ML, Ibrahim A, Adeyemo GD, Fadare M, Charurat M, Ezeanolue EE, Sam-Agudu NA. Exploring the acceptability of Option B plus among HIV-positive Nigerian women engaged and not engaged in the prevention of mother-to-child transmission of HIV cascade: a qualitative study. SAHARA J 2018; 15:128-137. [PMID: 30253709 PMCID: PMC6161587 DOI: 10.1080/17290376.2018.1527245] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The acceptability of lifelong antiretroviral therapy (ART) among HIV-positive women in high-burden Nigeria, is not well-known. We explored readiness of users and providers of prevention of mother-to-child transmission of HIV (PMTCT) services to accept lifelong ART -before Option B plus was implemented in Nigeria. We conducted 142 key informant interviews among 100 PMTCT users (25 pregnant-newly-diagnosed, 26 pregnant-in-care, 28 lost-to-follow-up (LTFU) and 21 postpartum women living with HIV) and 42 PMTCT providers in rural North-Central Nigeria. Qualitative data were manually analyzed via Grounded Theory. PMTCT users had mixed views about lifelong ART, strongly influenced by motivation to prevent infant HIV and by presence or absence of maternal illness. Newly-diagnosed women were most enthusiastic about lifelong ART, however postpartum and LTFU women expressed conditionalities for acceptance and adherence, including minimal ART side effects and potentially serious maternal illness. Providers corroborated user findings, identifying the postpartum period as problematic for lifelong ART acceptability/adherence. Option B plus scale-up in Nigeria will require proactively addressing PMTCT user fears about ART side effects, and continuous education on long-term maternal and infant benefits. Structural barriers such as the availability of trained providers, long clinic wait times and patient access to ART should also be addressed.
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Affiliation(s)
- Salome C Erekaha
- a International Research Center of Excellence, Institute of Human Virology Nigeria , Abuja , Nigeria
| | - Llewellyn J Cornelius
- b School of Social Work and College of Public Health, University of Georgia Athens , USA
| | - Melissa L Bessaha
- c School of Social Welfare, Health Sciences Center , Stony Brook , NY , USA
| | - Abdulmumin Ibrahim
- d Faculty of Basic Medical Sciences , College of Health Sciences, University of Ilorin , Ilorin , Nigeria.,e Faculty of Health Sciences, Department of Human Biology , University of Cape Town , Cape Town , South Africa
| | | | | | - Manhattan Charurat
- h Department of Epidemiology and Public Health and Director, Division of Epidemiology and Prevention , Institute of Human Virology, University of Maryland School of Medicine , Baltimore , USA
| | - Echezona E Ezeanolue
- i Healthy Sunrise Foundation , Las Vegas , USA.,j Faculty of Medical Sciences and Dentistry, Department of Paediatrics and Child Health , University of Nigeria , Enugu , Nigeria
| | - Nadia A Sam-Agudu
- a International Research Center of Excellence, Institute of Human Virology Nigeria , Abuja , Nigeria.,k Division of Epidemiology and Prevention, Department of Paediatrics and Faculty , Institute of Human Virology, University of Maryland School of Medicine , Baltimore , USA
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Kiwanuka G, Kiwanuka N, Muneza F, Nabirye J, Oporia F, Odikro MA, Castelnuovo B, Wanyenze RK. Retention of HIV infected pregnant and breastfeeding women on option B+ in Gomba District, Uganda: a retrospective cohort study. BMC Infect Dis 2018; 18:533. [PMID: 30355356 PMCID: PMC6201534 DOI: 10.1186/s12879-018-3450-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 10/16/2018] [Indexed: 12/12/2022] Open
Abstract
Background Lifelong antiretroviral therapy for HIV infected pregnant and lactating women (Option B+) has been rapidly scaled up but there are concerns about poor retention of women initiating treatment. However, facility-based data could underestimate retention in the absence of measures to account for self-transfers to other facilities. We assessed retention-in-care among women on Option B+ in Uganda, using facility data and follow-up to ascertain transfers to other facilities. Methods In a 25-month retrospective cohort analysis of routine program data, women who initiated Option B+ between March 2013 and March 2015 were tracked and interviewed quantitatively and qualitatively (in-depth interviews). Kaplan Meier survival analysis was used to estimate time to loss-to-follow-up (LTFU) while multivariable Cox proportional hazards regression was applied to estimate the adjusted predictors of LTFU, based on facility data. Thematic analysis was done for qualitative data, using MAXQDA 12. Quantitative data were analyzed with STATA® 13. Results A total of 518 records were reviewed. The mean (SD) age was 26.4 (5.5) years, 289 women (55.6%) attended primary school, and 53% (276/518) had not disclosed their HIV status to their partners. At 25 months post-ART initiation, 278 (53.7%) were LTFU based on routine facility data, with mean time to LTFU of 15.6 months. Retention was 60.2 per 1000 months of observation (pmo) (95% CI: 55.9–64.3) at 12, and 46.3/1000pmo (95% CI: 42.0–50.5) at 25 months. Overall, 237 (55%) women were successfully tracked and interviewed and 43/118 (36.4%) of those who were classified as LTFU at facility level had self-transferred to another facility. The true 25 months post-ART initiation retention after tracking was 71.3% (169/237). Women < 25 years, aHR = 1.71 (95% CI: 1.28–2.30); those with no education, aHR = 5.55 (95% CI: 3.11–9.92), and those who had not disclosed their status to their partners, aHR = 1.59 (95% CI: 1.16–2.19) were more likely to be LTFU. Facilitators for Option B+ retention based on qualitative findings were adequate counselling, disclosure, and the desire to stay alive and raise HIV-free children. Drug side effects, inadequate counselling, stigma, and unsupportive spouses, were barriers to retention in care. Conclusions Retention under Option B+ is suboptimal and is under-estimated at health facility level. There is need to institute mechanisms for tracking of women across facilities. Retention could be enhanced through strategies to enhance disclosure to partners, targeting the uneducated, and those < 25 years.
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Affiliation(s)
- George Kiwanuka
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O Box 7072, Kampala, Uganda.
| | - Noah Kiwanuka
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Fiston Muneza
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Juliet Nabirye
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O Box 7072, Kampala, Uganda
| | - Frederick Oporia
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | - Magdalene A Odikro
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Barbara Castelnuovo
- Department of Research, Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
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Challenges and opportunities for outreach workers in the Prevention of Mother to Child Transmission of HIV (PMTCT) program in India. PLoS One 2018; 13:e0203425. [PMID: 30180186 PMCID: PMC6122806 DOI: 10.1371/journal.pone.0203425] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 08/21/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The Prevention of Mother-to-Child Transmission of HIV (PMTCT) program in India is one of the largest in the world. It uses outreach workers (ORWs) to facilitate patient uptake of services, however, the challenges faced by the ORWs, and their views about the effectiveness of this program are unknown. METHODS The COMmunity-Home Based INDia (COMBIND) Prevention of Mother to Child Transmission of HIV study evaluated an integrated mobile health and behavioral intervention to enhance the capacity of ORWs in India. To understand the challenges faced by ORWs, and their perceptions of opportunities for program improvement, four group discussions were conducted among 60 ORW from four districts of Maharashtra, India, as part of the baseline assessment for COMBIND. Data were qualitatively analyzed using a thematic approach. RESULTS Numerous personal-, social-, and structural-level challenges existed for ORW as they engaged with their patients. Personal-level challenges for ORWs included disclosure of their own HIV status and travelling costs for home visits. Personal-level challenges for patients included financial costs of travelling to ART centers, non-adherence to ART, loss of daily wages, non-affordability of infant formula, lack of awareness of the baby's needs, financial dependence on family, four time points (6weeks, 6 months, 12 months and 18 months) for HIV tests, and need for nevirapine (NVP) prophylaxis. Social-level challenges included lack of motivation by patients and/or health care staff, social stigma, and rude behavior of health care staff and their unwillingness to provide maternity services to women in the PMTCT programme. Structural-level challenges included cultural norms around infant feeding, shortages of HIV testing kits, shortages of antiretroviral drugs and infant NVP prophylaxis, and lack of training/knowledge related to PMTCT infant feeding guidelines by hospital staff. The consensus among ORWs was that there was a critical need for tools and training to improve their capacity to effectively engage with patients, and deliver appropriate care, and for motivation through periodic feedback. CONCLUSIONS Given the significant challenges in PMTCT programme implementation reported by ORW, novel strategies to address these challenges are urgently needed to improve patient engagement, and access to and retention in care.
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Wilson KS, Wanje G, Masese L, Simoni JM, Shafi J, Adala L, Overbaugh J, Jaoko W, Richardson BA, McClelland RS. A Prospective Cohort Study of Fertility Desire, Unprotected Sex, and Detectable Viral Load in HIV-Positive Female Sex Workers in Mombasa, Kenya. J Acquir Immune Defic Syndr 2018; 78:276-282. [PMID: 29543635 PMCID: PMC5997523 DOI: 10.1097/qai.0000000000001680] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Little is known about fertility desire in HIV-positive female sex workers. Fertility desire could increase HIV transmission risk if it was associated with condomless sex or lower adherence to antiretroviral therapy. METHODS A prospective cohort study was conducted among 255 HIV-positive female sex workers in Mombasa, Kenya. Using generalized estimating equations, fertility desire was evaluated as a risk factor for semen detection in vaginal secretions by prostate-specific antigen (PSA) test, a biomarker of condomless sex, detectable plasma viral load (VL), and HIV transmission potential, defined as visits with positive PSA and detectable VL. RESULTS The effect of fertility desire on PSA detection varied significantly by nonbarrier contraception use (P-interaction < 0.01). At visits when women reported not using nonbarrier contraception, fertility desire was associated with higher risk of semen detection [82/385, 21.3% vs. 158/1007, 15.7%; adjusted relative risk (aRR) 1.58, 95% confidence interval (CI): 1.12 to 2.23]. However, when women used nonbarrier contraception, fertility desire was associated with lower risk of PSA detection (10/77, 13.0% vs. 121/536, 22.6%; aRR 0.58, 95% CI: 0.35 to 0.94). Fertility desire was not associated with detectable VL (31/219, 14.2% vs. 128/776, 16.5%; aRR 0.82, 95% CI: 0.46 to 1.45) or higher absolute risk of transmission potential (10/218, 4.6% vs. 21/769, 2.7%; adjusted risk difference = 0.011, 95% CI -0.031 to 0.050). CONCLUSIONS Fertility desire was associated with higher risk of biological evidence of semen exposure when women were not using nonbarrier contraceptives. Low HIV transmission potential regardless of fertility desire suggests that the combination of condoms and antiretroviral therapy adherence was effective.
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Affiliation(s)
| | | | | | | | | | | | - Julie Overbaugh
- Human Biology and Public Health Sciences Divisions, Fred Hutchison Cancer Research Center, Seattle, WA
| | | | - Barbra A Richardson
- Human Biology and Public Health Sciences Divisions, Fred Hutchison Cancer Research Center, Seattle, WA
| | - Raymond S McClelland
- Medicine
- Epidemiology, University of Washington, Seattle, WA
- University of Nairobi, Nairobi, Kenya
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Deschamps MM, Jannat-Khah D, Rouzier V, Bonhomme J, Pierrot J, Lee MH, Abrams E, Pape J, McNairy ML. Fifteen years of HIV and syphilis outcomes among a prevention of mother-to-child transmission program in Haiti: from monotherapy to Option B. Trop Med Int Health 2018; 23:724-737. [PMID: 29779260 DOI: 10.1111/tmi.13075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To evaluate mother and infant outcomes in the largest prevention of mother-to-child-transmission (PMTCT) programme in Haiti in order to identify gaps towards elimination of HIV and syphilis. METHODS Based on retrospective data from HIV+ pregnant women and their infants enrolled in PMTCT care from 1999 to 2014, we assessed maternal enrolment in PMTCT, receipt of antiretrovirals before delivery, maternal retention through delivery as well as infant enrolment in PMTCT, HIV testing and HIV infection. Four PMTCT programme periods were compared: period 1 (1999-2004, mono ARV), period 2 (2005-2009, dual ARV), period 3 (2010-2012, Option B) and period 4 (Oct 2012-2014, Option B+). Kaplan-Meier methods were used to assess retention in PMTCT care. RESULTS Among 4665 pregnancies, median age was 27 years and median CD4+ was 494 cells/μl (IQR 328-691). A total of 75% of women received antiretrovirals before delivery, and 73% were retained in care through delivery. Twenty-two percent of women were lost before delivery, <1% died and 6% had stillbirths or abortions. Ninety-four percent of infants who were born alive enrolled in PMTCT, of whom 92% had complete HIV testing. One hundred and sixty-one infants were HIV+, giving a 5.4% HIV transmission rate (9.8%, 4.6%, 5.8% and 3.6% in periods 1-4). Retention among women through 12 months after PMTCT enrolment did not significantly differ across periods. However, among women who received antiretrovirals at the time of enrolment, retention 12 months later was lower in the Option B+ period (83%) than in periods 2 and 3 (94% and 93%) (P < 0.001). Syphilis infection among women decreased from 16% in period 1 to 8% in period 4, whereas syphilis testing of infants increased from 17% to 91%. CONCLUSION Despite dramatic reductions in MTCT in Haiti, interventions are needed to improve retention to achieve MTCT elimination of HIV and syphilis.
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Affiliation(s)
- Marie Marcelle Deschamps
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port au Prince, Haiti
| | - Deanna Jannat-Khah
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Vanessa Rouzier
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port au Prince, Haiti
| | - Jerry Bonhomme
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port au Prince, Haiti
| | - Julma Pierrot
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port au Prince, Haiti
| | - Myung Hee Lee
- Center for Global Health, Weill Cornell Medicine, New York, NY, USA
| | - Elaine Abrams
- ICAP and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Jean Pape
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port au Prince, Haiti.,Center for Global Health, Weill Cornell Medicine, New York, NY, USA
| | - Margaret L McNairy
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA.,Center for Global Health, Weill Cornell Medicine, New York, NY, USA
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Yourkavitch J, Hassmiller Lich K, Flax VL, Okello ES, Kadzandira J, Katahoire AR, Munthali AC, Thomas JC. Interactions among poverty, gender, and health systems affect women's participation in services to prevent HIV transmission from mother to child: A causal loop analysis. PLoS One 2018; 13:e0197239. [PMID: 29775467 PMCID: PMC5959065 DOI: 10.1371/journal.pone.0197239] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 04/28/2018] [Indexed: 11/20/2022] Open
Abstract
Retention in care remains an important issue for prevention of mother-to-child transmission (PMTCT) programs according to WHO guidelines, formerly called the “Option B+” approach. The objective of this study was to examine how poverty, gender, and health system factors interact to influence women’s participation in PMTCT services. We used qualitative research, literature, and hypothesized variable connections to diagram causes and effects in causal loop models. We found that many factors, including antiretroviral therapy (ART) use, service design and quality, stigma, disclosure, spouse/partner influence, decision-making autonomy, and knowledge about PMTCT, influence psychosocial health, which in turn affects women’s participation in PMTCT services. Thus, interventions to improve psychosocial health need to address many factors to be successful. We also found that the design of PMTCT services, a modifiable factor, is important because it affects several other factors. We identified 66 feedback loops that may contribute to policy resistance—that is, a policy’s failure to have its intended effect. Our findings point to the need for a multipronged intervention to encourage women’s continued participation in PMTCT services and for longitudinal research to quantify and test our causal loop model.
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Affiliation(s)
- Jennifer Yourkavitch
- MEASURE Evaluation, Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina, United States of America
- ICF, Rockville, Maryland, United States of America
- * E-mail:
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Valerie L. Flax
- MEASURE Evaluation, Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina, United States of America
- RTI International, Durham, North Carolina, United States of America
| | - Elialilia S. Okello
- Department of Psychiatry, Makerere University, Kampala, Uganda
- Child Health and Development Centre, Makerere University, Kampala, Uganda
| | - John Kadzandira
- Centre for Social Research, Chancellor College, University of Malawi, Zomba, Malawi
| | | | - Alister C. Munthali
- Centre for Social Research, Chancellor College, University of Malawi, Zomba, Malawi
| | - James C. Thomas
- MEASURE Evaluation, Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina, United States of America
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
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Reproduction and Fertility Beliefs, Perceptions, and Attitudes in People Living with HIV. AIDS Res Treat 2018; 2018:5349793. [PMID: 29805805 PMCID: PMC5899855 DOI: 10.1155/2018/5349793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 02/21/2018] [Indexed: 11/17/2022] Open
Abstract
People living with HIV (PLWH) have distinct needs when it comes to reproductive health, specifically regarding fertility, family planning, and pregnancy, and these needs are often complicated by HIV status. While there is ample research that focuses on reproductive health in PLWH through a quantitative lens, there is a lack of research using qualitative methods, namely, the narrative interview model. We searched PubMed and relevant abstracts to identify 72 articles published from 1997 to 2016 that described a qualitative framework for exploring the behaviors and perceptions regarding family planning, abortion, pregnancy, parenthood, fertility, and forced sterility in PLWH. The inclusion criteria initially showed 147 articles, which were further screened to exclude those that did not address fertility and family planning specifically. Our final sample of articles included articles related to qualitative research on reproductive attitudes, beliefs, and behaviors of PLWH. Several of these articles were mixed-methods analyses, but our focus was on the qualitative portion only. Further qualitative works in this area will not only contribute to gaps quantitative research in the field cannot capture by design, but also inform clinical practice, policy, and interventions through systematic, in-depth evaluation.
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Clouse K, Mongwenyana C, Musina M, Bokaba D, Long L, Maskew M, Ahonkhai A, Fox MP. Acceptability and feasibility of a financial incentive intervention to improve retention in HIV care among pregnant women in Johannesburg, South Africa. AIDS Care 2017; 30:453-460. [PMID: 29067861 DOI: 10.1080/09540121.2017.1394436] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Women initiating antiretroviral therapy during pregnancy are at high risk of dropping out of HIV care after delivery. We assessed the acceptability and feasibility of a financial incentive - a one-time R50 (∼USD4) supermarket voucher for completing one postpartum visit ≤10 weeks of delivery - to improve postpartum retention. We enrolled 100 pregnant, HIV-positive women at a primary health clinic in Johannesburg, South Africa. Participants were interviewed at enrollment and we reviewed files to assess retention ≥14 weeks postpartum. Median (IQR) respondent age was 28 years (24-31) and 31% were employed. Most (86%) said the incentive would motivate them to return and 76% supported clinics offering incentives. Among the 23% who found the intervention unacceptable, the most frequent reason was perceived personal responsibility for health. Feasibility was demonstrated, as 79.7% (51/64) of eligible participants received a voucher. When asked to rank preferred hypothetical incentive interventions, assistance with social services ranked first (29%), followed by infant formula (22%) and cash (21%); assistance with social services was the top-ranked choice by both those who found the voucher incentive intervention acceptable and unacceptable. To encourage HIV-positive women to remain in care, respondents most frequently suggested health education (34%), counseling (29%), financial incentives (25%), home visits (13%), and better service (6%). Our results suggest financial incentives are acceptable, but women frequently expressed preference for integrated services and improved education and counseling to improve retention. Interventions exploring the feasibility and efficacy of education and counseling interventions to improve postpartum HIV care are warranted.
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Affiliation(s)
- Kate Clouse
- a Vanderbilt Institute for Global Health , Vanderbilt University , Nashville , TN , USA.,b Department of Medicine, Division of Infectious Diseases , Vanderbilt University , Nashville , TN , USA.,c Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Constance Mongwenyana
- c Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Melda Musina
- c Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Dorah Bokaba
- d Hikhensile Clinic , City of Johannesburg , Johannesburg , South Africa
| | - Lawrence Long
- c Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Mhairi Maskew
- c Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Aima Ahonkhai
- a Vanderbilt Institute for Global Health , Vanderbilt University , Nashville , TN , USA.,b Department of Medicine, Division of Infectious Diseases , Vanderbilt University , Nashville , TN , USA
| | - Matthew P Fox
- c Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa.,e Department of Global Health , Boston University School of Public Health, Boston University , Boston , MA , USA.,f Department of Epidemiology , Boston University School of Public Health, Boston University , Boston , MA , USA
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McLean E, Renju J, Wamoyi J, Bukenya D, Ddaaki W, Church K, Zaba B, Wringe A. 'I wanted to safeguard the baby': a qualitative study to understand the experiences of Option B+ for pregnant women and the potential implications for 'test-and-treat' in four sub-Saharan African settings. Sex Transm Infect 2017; 93:sextrans-2016-052972. [PMID: 28736391 PMCID: PMC5739848 DOI: 10.1136/sextrans-2016-052972] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 03/24/2017] [Accepted: 04/03/2017] [Indexed: 11/04/2022] Open
Abstract
Objective To explore what influences on engagement with Option B+ in four sub-Saharan African settings. Methods In-depth interviews were conducted in 2015, with 22 HIV-positive women who had been pregnant since Option B+ was available, and 15 healthcare workers (HCWs) involved in HIV service delivery. Participants were purposely selected from four health and demographic surveillance sites in Malawi, Tanzania and Uganda. A thematic content analysis was conducted to investigate what influenced engagement with Option B+. Results Feeling ‘ready’ was key to pregnant women accepting antiretroviral treatment (ART) on the same day as diagnosis at antenatal clinic; this was influenced by previous knowledge of HIV-positive status, interactions with HCWs and relationship with their partners. The desire to protect their unborn infant was the main issue that motivated women to initiate treatment, temporarily over-riding barriers to starting ART. Many HCWs recognised that pressurising women into starting ART may lead them to stop treatment following delivery. However, their own responsibility to protect the infant sometimes drove HCWs to use strong persuasive techniques to initiate pregnant women onto ART as early as possible, occasionally causing women to disengage. Conclusions Protecting the baby superseded feelings of unpreparedness for lifelong ART and may explain poor retention observed in Option B+ programmes. Women may benefit from more time to accept their status, and counselling on the long-term value of ART beyond the pregnancy and breastfeeding period. Strategies to promote readiness for same-day initiation of lifelong treatment are urgently needed, and may provide important lessons for universal test-and-treat implementation.
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Affiliation(s)
- Estelle McLean
- Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi.,Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jenny Renju
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Joyce Wamoyi
- National Institute for Medical Research, Mwanza, Tanzania
| | - Dominic Bukenya
- Medical Research Council/Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
| | | | - Kathryn Church
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Basia Zaba
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Alison Wringe
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Naburi H, Mujinja P, Kilewo C, Orsini N, Bärnighausen T, Manji K, Biberfeld G, Sando D, Geldsetzer P, Chalamila G, Ekström AM. Job satisfaction and turnover intentions among health care staff providing services for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania. HUMAN RESOURCES FOR HEALTH 2017; 15:61. [PMID: 28874156 PMCID: PMC5585985 DOI: 10.1186/s12960-017-0235-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 08/25/2017] [Indexed: 05/31/2023]
Abstract
BACKGROUND Option B+ for the prevention of mother-to-child transmission (PMTCT) of HIV (i.e., lifelong antiretroviral treatment for all pregnant and breastfeeding mothers living with HIV) was initiated in Tanzania in 2013. While there is evidence that this policy has benefits for the health of the mother and the child, Option B+ may also increase the workload for health care providers in resource-constrained settings, possibly leading to job dissatisfaction and unwanted workforce turnover. METHODS From March to April 2014, a questionnaire asking about job satisfaction and turnover intentions was administered to all nurses at 36 public-sector health facilities offering antenatal and PMTCT services in Dar es Salaam, Tanzania. Multivariable logistic regression models were used to identify factors associated with job dissatisfaction and intention to quit one's job. RESULTS Slightly over half (54%, 114/213) of the providers were dissatisfied with their current job, and 35% (74/213) intended to leave their job. Most of the providers were dissatisfied with low salaries and high workload, but satisfied with workplace harmony and being able to follow their moral values. The odds of reporting to be globally dissatisfied with one's job were high if the provider was dissatisfied with salary (adjusted odds ratio (aOR) 5.6, 95% CI 1.2-26.8), availability of protective gear (aOR 4.0, 95% CI 1.5-10.6), job description (aOR 4.3, 95% CI 1.2-14.7), and working hours (aOR 3.2, 95% CI 1.3-7.6). Perceiving clients to prefer PMTCT Option B+ reduced job dissatisfaction (aOR 0.2, 95% CI 0.1-0.8). The following factors were associated with providers' intention to leave their current job: job stability dissatisfaction (aOR 3.7, 95% CI 1.3-10.5), not being recognized by one's superior (aOR 3.6, 95% CI 1.7-7.6), and poor feedback on the overall unit performance (aOR 2.7, 95% CI 1.3-5.8). CONCLUSION Job dissatisfaction and turnover intentions are comparatively high among nurses in Dar es Salaam's public-sector maternal care facilities. Providing reasonable salaries and working hours, clearer job descriptions, appropriate safety measures, job stability, and improved supervision and feedback will be key to retaining satisfied PMTCT providers and thus to sustain successful implementation of Option B+ in Tanzania.
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Affiliation(s)
- Helga Naburi
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania.
| | - Phares Mujinja
- School of Public Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Charles Kilewo
- Departments of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Nicola Orsini
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
- Africa Health Research Institute (AHRI), Mtubatuba, South Africa
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Karim Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Gunnel Biberfeld
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - David Sando
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
- Management and Development for Health (MDH) Organisation, Dar es Salaam, Tanzania
| | - Pascal Geldsetzer
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Guerino Chalamila
- Management and Development for Health (MDH) Organisation, Dar es Salaam, Tanzania
| | - Anna Mia Ekström
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Huddinge, Stockholm, Sweden
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Naigino R, Makumbi F, Mukose A, Buregyeya E, Arinaitwe J, Musinguzi J, Wanyenze RK. HIV status disclosure and associated outcomes among pregnant women enrolled in antiretroviral therapy in Uganda: a mixed methods study. Reprod Health 2017; 14:107. [PMID: 28854944 PMCID: PMC5577683 DOI: 10.1186/s12978-017-0367-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 08/16/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Disclosure of HIV positive status to sexual partners is promoted by HIV prevention programs including those targeting the prevention of mother-to-child transmission. Among other benefits, disclosure may enhance spousal support and reduce stigma, violence and discrimination. HIV status disclosure and associated outcomes were assessed among a cohort of women, newly initiating lifelong antiretroviral therapy in Uganda between October 2013 and May 2014. METHODS This was a mixed method study, drawing data from a prospective cohort study of 507 HIV positive pregnant women on lifelong antiretroviral therapy, who were followed for four months to determine disclosure and its outcomes. Women were recruited from three facilities for the cohort study; in addition, fifty-seven women were recruited to participate in qualitative interviews from six facilities. Factors associated with spousal support and negative outcomes were determined using random-effects logistic regression in two separate models, with prevalence ratio as measure of association. In-depth interviews were used to document experiences with disclosure of HIV status. RESULTS Overall HIV status disclosure to at least one person was high [(375/507), 83.7%]. Nearly three-quarters [(285/389), 73.3%], had disclosed to their spouse by the fourth month of follow up post-enrolment. Among married women, spousal support was high at the first 330/407 (81.1%) and second follow-up 320/389 (82.2%). The majority of women who reported spousal support for either antenatal care or HIV-related care services had disclosed their HIV status to their spouses (adj.PR = 1.17; 95% CI: 1.02-1.34). However, no significant differences were observed in the proportion of self-reported negative outcomes by HIV status disclosure (adj.PR = 0.89; 95% CI: 0.56-1.42). Qualitative findings highlighted stigma and fear of negative outcomes as the major barriers to disclosure. CONCLUSION HIV status disclosure to partners by pregnant women on lifelong antiretroviral therapy was associated with increased spousal support, but was impeded by fear of adverse outcomes such as stigma, discrimination and violence. Interventions to reduce negative outcomes could enhance HIV status disclosure.
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Affiliation(s)
- Rose Naigino
- GF-PMTCT Study, Makerere University School of Public Health, Kampala, Uganda.
| | - Fredrick Makumbi
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Aggrey Mukose
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Esther Buregyeya
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | | | | | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
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Chadambuka A, Katirayi L, Muchedzi A, Tumbare E, Musarandega R, Mahomva AI, Woelk G. Acceptability of lifelong treatment among HIV-positive pregnant and breastfeeding women (Option B+) in selected health facilities in Zimbabwe: a qualitative study. BMC Public Health 2017; 18:57. [PMID: 28743251 PMCID: PMC5526299 DOI: 10.1186/s12889-017-4611-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 07/19/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Zimbabwe's Ministry of Health and Child Care (MOHCC) adopted 2013 World Health Organization (WHO) prevention of mother-to-child HIV transmission (PMTCT) guidelines recommending initiation of HIV-positive pregnant and breastfeeding women (PPBW) on lifelong antiretroviral treatment (ART) irrespective of clinical stage (Option B+). Option B+ was officially launched in Zimbabwe in November 2013; however the acceptability of life-long ART and its potential uptake among women was not known. METHODS A qualitative study was conducted at selected sites in Harare (urban) and Zvimba (rural) to explore Option B+ acceptability; barriers, and facilitators to ART adherence and service uptake. In-depth interviews (IDIs), focus group discussions (FGDs) and key informant interviews (KIIs) were conducted with PPBW, healthcare providers, and community members. All interviews were audio-recorded, transcribed, and translated; data were coded and analyzed in MaxQDA v10. RESULTS Forty-three IDIs, 22 FGDs, and five KIIs were conducted. The majority of women accepted lifelong ART. There was however, a fear of commitment to taking lifelong medication because they were afraid of defaulting, especially after cessation of breastfeeding. There was confusion around dosage; and fear of side effects, not having enough food to take drugs, and the lack of opportunities to ask questions in counseling. Participants reported the need for strengthening community sensitization for Option B+. Facilitators included receiving a simplified pill regimen; ability to continue breastfeeding beyond 6 months like HIV-negative women; and partner, community and health worker support. Barriers included distance of health facility, non-disclosure of HIV status, poor male partner support and knowing someone who had negative experience on ART. CONCLUSIONS This study found that Option B+ is generally accepted among PPBW as a means to strengthen their health and protect their babies. Consistent with previous literature, this study demonstrated the importance of male partner and community support in satisfactory adherence to ART and enhancing counseling techniques. Strengthening community sensitization and male knowledge is critical to encourage women to disclose their HIV status and ensure successful adherence to ART. Targeting and engaging partners of women will remain key determinants to women's acceptance and adherence on ART under Option B+.
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Affiliation(s)
- Addmore Chadambuka
- Elizabeth Glaser Pediatric AIDS Foundation, 107 King George Road, Avondale, Harare, Zimbabwe.
| | - Leila Katirayi
- Elizabeth Glaser Pediatric AIDS Foundation, Washington DC, USA
| | - Auxilia Muchedzi
- Elizabeth Glaser Pediatric AIDS Foundation, 107 King George Road, Avondale, Harare, Zimbabwe
| | - Esther Tumbare
- Elizabeth Glaser Pediatric AIDS Foundation, 107 King George Road, Avondale, Harare, Zimbabwe
| | - Reuben Musarandega
- Elizabeth Glaser Pediatric AIDS Foundation, 107 King George Road, Avondale, Harare, Zimbabwe
| | - Agnes I Mahomva
- Elizabeth Glaser Pediatric AIDS Foundation, 107 King George Road, Avondale, Harare, Zimbabwe
| | - Godfrey Woelk
- Elizabeth Glaser Pediatric AIDS Foundation, Washington DC, USA
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Mobility and Clinic Switching Among Postpartum Women Considered Lost to HIV Care in South Africa. J Acquir Immune Defic Syndr 2017; 74:383-389. [PMID: 28225717 DOI: 10.1097/qai.0000000000001284] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Retention in HIV care, particularly among postpartum women, is a challenge to national antiretroviral therapy programs. Retention estimates may be underestimated because of unreported transfers. We explored mobility and clinic switching among patients considered lost to follow-up (LTFU). DESIGN Observational cohort study. METHODS Of 788 women initiating antiretroviral therapy during pregnancy at 6 public clinics in Johannesburg, South Africa, 300 (38.1%) were LTFU (no visit ≥3 months). We manually searched for these women in the South African National Health Laboratory Services database to assess continuity of HIV care. We used geographic information system tools to map mobility to new facilities. RESULTS Over one-third (37.6%) of women showed evidence of continued HIV care after LTFU. Of these, 67.0% continued care in the same province as the origin clinic. Compared with those who traveled outside of the province for care, these same-province "clinic shoppers" stayed out-of-care longer {median 373 days [interquartile range (IQR): 175-790] vs. 175.5 days (IQR: 74-371)} and had a lower CD4 cell count on re-entry [median 327 cells/μL (IQR: 196-576) vs. 493 cells/μL (IQR: 213-557). When considering all women with additional evidence of care as engaged in care, cohort LTFU dropped from 38.1% to 25.0%. CONCLUSIONS We found evidence of continued care after LTFU and identified local and national clinic mobility among postpartum women. Laboratory records do not show all clinic visits and manual matching may have been under- or overestimated. A national health database linked to a unique identifier is necessary to improve reporting and patient care among highly mobile populations.
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Ritt GC, Pereira MD, Levandowski DC. Analysing the experience of motherhood among adolescents living with HIV. PSYCHOLOGY, COMMUNITY & HEALTH 2017. [DOI: 10.5964/pch.v6i1.185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Aim
Adolescent motherhood is considered a condition of vulnerability that can be further complicated by the presence of HIV infection, but little is known about how adolescent mothers experience this process. The aim of this study was to analyse the experience of motherhood among adolescents living with HIV.
Method
Seven mothers (15-21 years) recruited in specialized services in Porto Alegre/Brazil, whose babies’ ages ranged from four to six months, were interviewed. Interviews were tape-recorded and transcribed verbatim.
Results
The qualitative content analysis of the interviews revealed a positive vision of motherhood, related to satisfaction with the maternal role and personal fulfilment. Pregnancy and motherhood served to these adolescents as an encouragement for self-care. The mothers’ difficulties were related to HIV and to the repercussions of this clinical condition, especially feelings of frustration and incompleteness of motherhood on the impossibility of breastfeeding, as well as fear facing the risk of MTCT.
Conclusion
Future research of longitudinal design and with larger samples will be important to extend the knowledge of the specificities of this experience over time for young people of different ages and social backgrounds.
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Buregyeya E, Naigino R, Mukose A, Makumbi F, Esiru G, Arinaitwe J, Musinguzi J, Wanyenze RK. Facilitators and barriers to uptake and adherence to lifelong antiretroviral therapy among HIV infected pregnant women in Uganda: a qualitative study. BMC Pregnancy Childbirth 2017; 17:94. [PMID: 28320347 PMCID: PMC5360052 DOI: 10.1186/s12884-017-1276-x] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 03/14/2017] [Indexed: 11/15/2022] Open
Abstract
Background In 2012, Uganda started implementing lifelong antiretroviral therapy (ART) for prevention of mother to child transmission (PMTCT) in line with the WHO 2012 guidelines. This study explored experiences of HIV infected pregnant and breastfeeding women regarding barriers and facilitators to uptake and adherence to lifelong ART. Methods This was a cross-sectional qualitative study conducted in three districts (Masaka, Mityana and Luwero) in Uganda, between February and May 2014. We conducted in-depth interviews with 57 pregnant and breastfeeding women receiving care in six health facilities, who had been on lifelong ART for at least 6 months. Data analysis was done using a content thematic approach with Atlas-ti software. Results Initiation of lifelong ART was done the same day the mother tested HIV positive. Several women felt the counselling was inadequate and had reservations about taking ART for life. The main motivation to initiate and adhere to ART was the desire to have an HIV-free baby. Adherence was a challenge, ranging from not taking the drugs at the right time, to completely missing doses and clinic appointments. Support from their male partners and peer family support groups enhanced good adherence. Fear to disclose HIV status to partners, drug related factors (side effects and the big size of the tablet), and HIV stigma were major barriers to ART initiation and adherence. Transition from antenatal care to HIV chronic care clinics was a challenge due to fear of stigma and discrimination. Conclusions In order to maximize the benefits of lifelong ART, adequate preparation of women before ART initiation and on-going support through family support groups and male partner engagement are critical, particularly after birth and cessation of breastfeeding.
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Affiliation(s)
- Esther Buregyeya
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.
| | - Rose Naigino
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Aggrey Mukose
- Department of Epidemiology and Biostatics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fred Makumbi
- Department of Epidemiology and Biostatics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Godfrey Esiru
- AIDS Control Program, Ministry of Health, Kampala, Uganda
| | - Jim Arinaitwe
- Global Fund Focal Coordination Office, Ministry of Health, Kampala, Uganda
| | | | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
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Drake AL, Unger JA, Ronen K, Matemo D, Perrier T, DeRenzi B, Richardson BA, Kinuthia J, John-Stewart G. Evaluation of mHealth strategies to optimize adherence and efficacy of Option B+ prevention of mother-to-child HIV transmission: Rationale, design and methods of a 3-armed randomized controlled trial. Contemp Clin Trials 2017; 57:44-50. [PMID: 28315480 DOI: 10.1016/j.cct.2017.03.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 03/01/2017] [Accepted: 03/13/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND Lifelong antiretroviral therapy (ART) (Option B+) is recommended for all HIV-infected pregnant/postpartum women, but high adherence is required to maximize HIV prevention potential and maintain maternal health. Mobile health (mHealth) interventions may provide treatment adherence support for women during, and beyond, the pregnancy and postpartum periods. METHODS AND DESIGN We are conducting an unblinded, triple-arm randomized clinical trial (Mobile WACh X) of one-way short message service (SMS) vs. two-way SMS vs. control (no SMS) to improve maternal ART adherence and retention in care by 2years postpartum. We will enroll 825 women from Nairobi and Western Kenya. Women in the intervention arms receive weekly, semi-automated motivational and educational SMS and visit reminders via an interactive, human-computer hybrid communication system. Participants in the two-way SMS arm are also asked to respond to a question related to the message. SMS are based in behavioral theory, are tailored to participant characteristics through SMS tracks, and are timed along the pregnancy/postpartum continuum. After enrollment, follow-up visits are scheduled at 6weeks; 6, 12, 18, and 24months postpartum. The primary outcomes, virological failure (HIV viral load ≥1000copies/mL), maternal retention in care, and infant HIV infection or death, will be compared in an intent to treat analysis. We will also measure ART adherence and drug resistance. DISCUSSION Personalized and tailored SMS to support HIV-infected women during and after pregnancy may be an effective strategy to motivate women to adhere to ART and remain in care and improve maternal and infant outcomes.
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Affiliation(s)
- Alison L Drake
- Department of Global Health, University of Washington, Box 359909, Seattle, WA 98195-7236, USA.
| | - Jennifer A Unger
- Departments of Global Health and Obstetrics and Gynecology, University of Washington, Box 359909, Seattle, WA 98195-7236, USA.
| | - Keshet Ronen
- Departments of Global Health and Epidemiology, University of Washington, Box 359909, Seattle, WA 98195-7236, USA.
| | - Daniel Matemo
- Department of Research and Programs, Kenyatta National Hospital, PO Box 20723-00202, Nairobi, Kenya.
| | - Trevor Perrier
- Department of Computer Science and Engineering, University of Washington, Box 352350, Seattle, WA 98195-7236, USA.
| | - Brian DeRenzi
- Department of Computer Science, University of Cape Town, Room 306, Computer Science Building, Cape Town, South Africa.
| | - Barbra A Richardson
- Department of Biostatistics, University of Washington, Box 359909, Seattle, WA 98195-7236, USA.
| | - John Kinuthia
- Department of Research and Programs, Kenyatta National Hospital, PO Box 20723-00202, Nairobi, Kenya.
| | - Grace John-Stewart
- Departments of Global Health, Medicine, Epidemiology, and Pediatrics, University of Washington, Box 359909, Seattle, WA 98195-7236, USA.
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Hampanda KM, Abuogi LL, Ahmed Y. HIV-Positive Women Taking Lifelong Antiretroviral Therapy Report Better Adherence Than Women Taking Short-Course Prophylaxis During and After Pregnancy Under PMTCT Program Option A in Lusaka, Zambia. Int J MCH AIDS 2017; 6:27-35. [PMID: 28798891 PMCID: PMC5547223 DOI: 10.21106/ijma.164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES HIV-positive women's adherence to antiretrovirals is critical for prevention of mother-to-child transmission. We aimed to establish if mothers taking triple lifelong antiretroviral therapy report higher adherence compared to mothers taking short-course prophylaxis under Option A in Lusaka, Zambia. METHODS In this clinic-based cross-sectional study, we interviewed 320 HIV-positive mothers at a large public health facility in Lusaka in 2014. Participants reported adherence using a visual analog scale. Multiple logistic regression models were used to determine the adjusted odds of adherence by mother's prescribed regimen. RESULTS Women taking lifelong triple antiretroviral therapy report higher adjusted odds of adherence during pregnancy, postpartum, and to giving the infant prophylaxis compared to women to women taking short-course prophylaxis. DISCUSSION Women on lifelong therapy may have better adherence compared to women on short course prophylaxis because they knew their positive status for longer or were symptomatic with HIV-related disease. The lifelong therapy regimen may be easier for women to follow, particularly because they are required to give the infant prophylaxis for a shorter duration of time. CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS Our results indicate that lifelong triple antiretroviral therapy has the potential to promote better drug adherence during and after pregnancy among women living with HIV in sub-Saharan Africa, compared to short-course antiretroviral regimens.
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Affiliation(s)
- Karen M Hampanda
- Department of Community and Behavioral Health, University of Colorado School of Public Health, Aurora, CO 80045, USA
| | - Lisa L Abuogi
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA.,Center for Global Health, University of Colorado School of Medicine, School of Public Health, Aurora, CO 80045, USA
| | - Yusuf Ahmed
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
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Atanga PN, Ndetan HT, Achidi EA, Meriki HD, Hoelscher M, Kroidl A. Retention in care and reasons for discontinuation of lifelong antiretroviral therapy in a cohort of Cameroonian pregnant and breastfeeding HIV-positive women initiating 'Option B+' in the South West Region. Trop Med Int Health 2016; 22:161-170. [PMID: 27865052 DOI: 10.1111/tmi.12816] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess linkage and retention in care along the PMTCT cascade in HIV-positive pregnant and breastfeeding women initiating Option B+ in Cameroon. METHODS We prospectively determined uptake of HIV testing and counselling (HTC), uptake of ART and retention in care after Option B+ initiation between October 2013 and December 2014 in pregnant and breastfeeding women from five sites within the Kumba Health District. Retention in care was assessed over at least 12 months follow-up and estimated by Kaplan-Meier analysis. During follow-up, tracing outcomes and reasons for discontinuing treatment were documented. RESULTS The uptake of HTC of 5813 women with unknown HIV status was 98.5%, 251 (4.4%) were newly diagnosed HIV positive, and ART uptake in women eligible to start Option B+ was 96.8%. We enrolled 268 women initiating lifelong ART in the follow-up. Overall, 65 (24.3%) discontinued treatment, either defined by loss to follow-up (44.6%) or actively stopped treatment (55.8%). Retention in care was 88.0% and 81.1% at 6 and 12 months, respectively. Discontinuation was significantly associated in multivariate analysis with small sites and high staff turnover [aOR 2.5 (95% CI 1.6, 3.9), P < 0.001]. Main reasons for stopping treatment were HIV status denial and stigma (52.8%), religious reasons (25.0%) and lack of transport fare (11.1%). CONCLUSION We observed good uptake of HTC, ART and retention in care, which declined over time. Discontinuation of Option B+ was highest at small sites with a high staff turnover. Improved staffing, adequate task shifting and community interventions to track defaulters including reducing stigma and religious beliefs may improve Option B+ retention.
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Affiliation(s)
- Pascal N Atanga
- Department of Public Health and Hygiene, University of Buea, Buea, Cameroon.,Centre for International Health, University of Munich, Munich, Germany
| | - Harrison T Ndetan
- Research Institute, Parker University, Dallas, TX, USA.,Department of Biostatistics and Epidemiology, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Eric A Achidi
- Faculty of Sciences, University of Buea, Buea, Cameroon
| | - Henry D Meriki
- Department of Microbiology and Parasitology, University of Buea, Buea, Cameroon.,Laboratory Department, Regional Hospital Buea, Buea, Cameroon
| | - Michael Hoelscher
- Centre for International Health, University of Munich, Munich, Germany.,Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich, Munich, Germany
| | - Arne Kroidl
- Centre for International Health, University of Munich, Munich, Germany.,German Centre for Infection Research, Partner Site Munich, Munich, Germany
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Naburi H, Mujinja P, Kilewo C, Bärnighausen T, Orsini N, Manji K, Biberfeld G, Sando D, Geldsetzer P, Chalamila G, Ekström AM. Predictors of Patient Dissatisfaction with Services for Prevention of Mother-To-Child Transmission of HIV in Dar es Salaam, Tanzania. PLoS One 2016; 11:e0165121. [PMID: 27768731 PMCID: PMC5074583 DOI: 10.1371/journal.pone.0165121] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 10/06/2016] [Indexed: 11/29/2022] Open
Abstract
Background Mother-to-child transmission (MTCT) of HIV remains a major source of new HIV infections in children. Prevention of mother-to-child transmission of HIV (PMTCT) using lifelong antiretroviral treatment (ART) for all pregnant and breastfeeding women living with HIV (Option B+) is the major strategy for eliminating paediatric HIV. Ensuring that patients are satisfied with PMTCT services is important for optimizing uptake, adherence and retention in treatment. Methods We conducted a facility based quantitative cross-sectional survey in Dar-es-Salaam, Tanzania, between March and April 2014, when the country was transitioning to the implementation of PMTCT Option B+. We interviewed 595 pregnant and breastfeeding women living with HIV, who received PMTCT care in 36 public health facilities. Predictors of overall dissatisfaction with PMTCT services were identified using a multiple logistic regression. Results Overall 8% of the patients expressed dissatisfaction with PMTCT services. Patients who perceived health care workers (HCW) communication skills as poor, had a 5-fold (OR 4.9, 95% CI 1.8–13.4) increased risk of dissatisfaction and those who perceived HCW capacity to understand client concerns as poor, had a 6-fold (OR 5.7, 95% CI 2.3–14.0) increased risk. Having a total visit time longer than two hours was associated with a 2-fold increased risk of being dissatisfied (OR 2.3, 95% CI 1.1–4.7). Every 30-minute increment in total visit time was associated with a 10% higher (OR 1.1, 95% CI 1.0–1.2) risk of being dissatisfied. The probability of being dissatisfied ranged from 4% (95% CI 2% - 6%) in the presence of patient-perceived good communication, good understanding of patient concerns, and a total visit time below two hours, to 70% (95% CI 47% - 86%) if HCW failed in all of these aspects. Conclusion Patient dissatisfaction with PMTCT services was generally low; reflecting that quality of care was maintained during Tanzania’s transition to Option B+ strategy aiming to increase the number of women initiating life-long ART in PMTCT clinics. Improved HCW communication with clients, their understanding of patient concerns and a reduction of the total visit time would further optimize women’s overall satisfaction with PMTCT services in Tanzania.
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Affiliation(s)
- Helga Naburi
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
- Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Phares Mujinja
- School of Public Health and Social Sciences (SPHSS), Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Charles Kilewo
- Departments of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
- Africa Centre for Population Health, Mtubatuba, South Africa
| | - Nicola Orsini
- Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
| | - Karim Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Gunnel Biberfeld
- Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
| | - David Sando
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
- Management and Development for Health (MDH) non-Governmental organization, Dar es Salaam, Tanzania
| | - Pascal Geldsetzer
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Guerino Chalamila
- Management and Development for Health (MDH) non-Governmental organization, Dar es Salaam, Tanzania
| | - Anna Mia Ekström
- Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Huddinge, Stockholm, Sweden
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Awiti PO, Grotta A, van der Kop M, Dusabe J, Thorson A, Mwangi J, Belloco R, Lester R, Ternent L, Were E, Ekström AM. The effect of an interactive weekly mobile phone messaging on retention in prevention of mother to child transmission (PMTCT) of HIV program: study protocol for a randomized controlled trial (WELTEL PMTCT). BMC Med Inform Decis Mak 2016; 16:86. [PMID: 27401475 PMCID: PMC4940723 DOI: 10.1186/s12911-016-0321-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 06/08/2016] [Indexed: 11/10/2022] Open
Abstract
Background Improving retention in prevention of mother to child transmission (PMTCT) of HIV programs is critical to optimize maternal and infant health outcomes, especially now that lifelong treatment is immediate regardless of CD4 cell count). The WelTel strategy of using weekly short message service (SMS) to engage patients in care in Kenya, where mobile coverage even in poor areas is widespread has been shown to improve adherence to antiretroviral therapy (ART) and viral load suppression among those on ART. The aim of this study is to determine the effect of the WelTel SMS intervention compared to standard care on retention in PMTCT program in Kenya. Methods WelTel PMTCT is a four to seven-centers, two-arm open randomized controlled trial (RCT) that will be conducted in urban and rural Kenya. Over 36 months, we plan to recruit 600 pregnant women at their first antenatal care visit and follow the mother-infant pair until they are discharged from the PMTCT program (when infant is aged 24 months). Participants will be randomly allocated to the intervention or control arm (standard care) at a 1:1 ratio. Intervention arm participants will receive an interactive weekly SMS ‘How are you?’ to which they are supposed to respond within 24 h. Depending on the response (ok, problem or no answer), a PMTCT nurse will follow-up and triage any problems that are identified. The primary outcome will be retention in care defined as the proportion of mother-infant pairs coming for infant HIV testing at 24 months from delivery. Secondary outcomes include a) adherence to WelTel; (b) adherence to antiretroviral medicine; (c) acceptance of WelTel and (d) cost-effectiveness of the WelTel intervention. Discussion This trial will provide evidence on the effectiveness of mHealth for PMTCT retention. Trial results and the cost-effectiveness evaluation will be used to inform policy and potential scale-up of mHealth among mothers living with HIV. Trial registration ISRCTN98818734; registered on 9th December 2014
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Affiliation(s)
- Patricia Opondo Awiti
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden.
| | - Alessandra Grotta
- Department of Medical Epidemiology and Statistics, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Mia van der Kop
- Division of Infectious diseases, University of British Columbia, Vancouver, Canada.,Division of Global Health, University of British Columbia, Vancouver, Canada.,Department of Public Health Sciences, 171 77, Stockholm, Sweden
| | - John Dusabe
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Anna Thorson
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Jonathan Mwangi
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Rino Belloco
- Department of Medical Epidemiology and Statistics, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Richard Lester
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | | | - Edwin Were
- Department of Reproductive Health, Moi University, P.O.BOX 3900-30100, Eldoret, Kenya
| | - Anna Mia Ekström
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
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HIV-positive pregnant and postpartum women's perspectives about Option B+ in Malawi: a qualitative study. J Int AIDS Soc 2016; 19:20919. [PMID: 27312984 PMCID: PMC4911420 DOI: 10.7448/ias.19.1.20919] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 04/28/2016] [Accepted: 05/12/2016] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION The implementation of lifelong antiretroviral treatment (ART) for all pregnant women (Option B+) in Malawi has resulted in a significant increase in the number of HIV-positive pregnant women initiating treatment. However, research has highlighted the challenge of retaining newly initiated women in care. This study explores barriers and facilitators that affect a woman's decision to initiate and to adhere to Option B+. METHODS A total of 39 in-depth interviews and 16 focus group discussions were conducted. Eligible women were ≥18 years old, living with HIV and either pregnant and receiving antenatal care from a study site or had delivered a child within the last 18 months, breastfed their child and received services at one of the study sites. Eligible women were identified by healthcare workers (HCWs) in the antenatal clinic and ART unit. Focus groups were also conducted with HCWs employed in these departments. Qualitative data were analyzed using Maxqda version 10 (VERBI Software, Berlin, Germany). RESULTS The general perception towards the drug regimen used in Option B+ was positive; women reported fewer side effects and acknowledged the positive benefits of ART. Women felt hopeful about prolonging their life and having an HIV-uninfected baby, yet grappled with the fact that ART is a lifelong commitment. Women and HCWs discussed challenges with the counselling services for prevention of mother-to-child HIV transmission under the new Option B+ guidelines, and many women struggled with initiating ART on the same day as learning their HIV status. Women wanted to discuss their circumstances with their husbands first, receive a CD4 count and obtain an HIV test at another facility to confirm their HIV status. HCWs expressed concern that women might just agree to take the drugs to please them. HCWs also discussed concerns around loss to follow-up and drug resistance. CONCLUSIONS Although Option B+ has significantly increased the number of women initiating ART, there are still challenges that need to be addressed to strengthen initiation, adherence and retention in care. Strategies to strengthen the counselling services upon diagnosis need to be developed to improve same-day initiation of ART and long-term adherence.
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Mitiku I, Arefayne M, Mesfin Y, Gizaw M. Factors associated with loss to follow-up among women in Option B+ PMTCT programme in northeast Ethiopia: a retrospective cohort study. J Int AIDS Soc 2016; 19:20662. [PMID: 27005750 PMCID: PMC4803835 DOI: 10.7448/ias.19.1.20662] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 02/09/2016] [Accepted: 02/23/2016] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Ethiopia has recently adopted lifelong antiretroviral therapy (ART) for all HIV-positive pregnant and breastfeeding women (Option B+ strategy), regardless of CD4 count or clinical stage. However, the exact timing and predictors of loss to follow-up (LFU) are unknown. Thus, we examined the levels and determinants of LFU under Option B+ among pregnant and breastfeeding women initiated on lifelong ART for prevention of mother-to-child transmission (PMTCT) in Ethiopia. METHODS We conducted a retrospective cohort study among 346 pregnant and breastfeeding women who started ART at 14 public health facilities in northeast Ethiopia from March 2013 to April 2015. We defined LFU as 90 days since the last clinic visit among those not known to have died or transferred out. We used Kaplan-Meier and Cox proportional hazards regression to estimate cumulative LFU and identify the predictors of LFU, respectively. RESULTS Of the 346 women included, 88.4% were pregnant and the median follow-up was 13.7 months. Overall, 57 (16.5%) women were LFU. The cumulative proportions of LFU at 6, 12 and 24 months were 11.9, 15.7 and 22.6%, respectively. The risk of LFU was higher in younger women (adjusted hazard ratio (aHR) 18 to 24 years/30 to 40 years: 2.3; 95% confidence interval (CI): 1.2 to 4.5), in those attending hospitals compared to those attending health centres (aHR: 1.8; 95% CI: 1.1 to 3.2), in patients starting ART on the same day of diagnosis (aHR: 1.85; 95% CI: 1.1 to 3.2) and missing CD4 cell counts at ART initiation (aHR: 2.3; 95% CI: 1.2 to 4.4). CONCLUSIONS The level of LFU we found in this study is comparable with previous findings from other resource-limited settings. However, high early LFU shortly after ART initiation is still a major problem. LFU was high among younger women, those initiating ART on the day of HIV diagnosis, those missing baseline CD4 count and those attending hospitals. Thus, targeted HIV care and treatment programmes for these patients should be part of future interventions to improve retention in care under the Option B+ PMTCT programme.
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Affiliation(s)
- Israel Mitiku
- Department of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia;
| | - Mastewal Arefayne
- Department of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Yonatal Mesfin
- Department of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Muluken Gizaw
- Department of Preventive Medicine, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Haas AD, Tenthani L, Msukwa MT, Tal K, Jahn A, Gadabu OJ, Spoerri A, Chimbwandira F, van Oosterhout JJ, Keiser O. Retention in care during the first 3 years of antiretroviral therapy for women in Malawi's option B+ programme: an observational cohort study. Lancet HIV 2016; 3:e175-82. [PMID: 27036993 DOI: 10.1016/s2352-3018(16)00008-4] [Citation(s) in RCA: 147] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 12/24/2015] [Accepted: 01/15/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Studies of Malawi's option B+ programme for HIV-positive pregnant and breastfeeding women have reported high loss to follow-up during pregnancy and at the start of antiretroviral therapy (ART), but few data exist about retention during breastfeeding and after weaning. We examined loss to follow-up and retention in care in patients in the option B+ programme during their first 3 years on ART. METHODS We analysed two data sources: aggregated facility-level data about patients in option B+ who started ART between Oct 1, 2011, and June 30, 2012, at 546 health facilities; and patient-level data from 20 large facilities with electronic medical record system for HIV-positive women who started ART between Sept 1, 2011, and Dec 31, 2013, under option B+ or because they had WHO clinical stages 3 or 4 disease or had CD4 counts of less than 350 cells per μL. We used facility-level data to calculate representative estimates of retention and loss to follow-up. We used patient-level data to study temporal trends in retention, timing of loss to follow-up, and predictors of no follow-up and loss to follow-up. We defined patients who were more than 60 days late for their first follow-up visit as having no follow-up and patients who were more than 60 days late for a subsequent visit as being lost to follow-up. We calculated proportions and cumulative probabilities of patients who had died, stopped ART, had no follow-up, were lost to follow-up, or were retained alive on ART for 36 months. We calculated odds ratios and hazard ratios to examine predictors of no follow-up and loss to follow-up. FINDINGS Analysis of facility-level data about patients in option B+ who had not transferred to a different facility showed retention in care to be 76·8% (20 475 of 26,658 patients) after 12 months, 70·8% (18,306 of 25,849 patients) after 24 months, and 69·7% (17,787 of 25,535 patients) after 36 months. Patient-level data included 29,145 patients. 14,630 (50·2%) began treatment under option B+. Patients in option B+ had a higher risk of having no follow-up and, for the first 2 years of ART, higher risk of loss to follow-up than did patients who started ART because they had CD4 counts less than 350 cells per μL or WHO clinical stage 3 or 4 disease. Risk of loss to follow-up during the third year was low and similar for patients retained for 2 years. Retention rates did not change as the option B+ programme matured. INTERPRETATION Our data suggest that pregnant and breastfeeding women who start ART immediately after they are diagnosed with HIV can be retained on ART through the option B+ programme, even after many have stopped breastfeeding. Interventions might be needed to improve retention in the first year on ART in option B+. FUNDING Bill & Melinda Gates Foundation, Partnerships for Enhanced Engagement in Research Health, and National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- Andreas D Haas
- Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland.
| | - Lyson Tenthani
- Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland; International Training & Education Center for Health Malawi (I-TECH), Lilongwe, Malawi
| | - Malango T Msukwa
- Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland; The Baobab Health Trust, Lilongwe, Malawi
| | - Kali Tal
- Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland
| | - Andreas Jahn
- International Training & Education Center for Health Malawi (I-TECH), Lilongwe, Malawi; Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | | | - Adrian Spoerri
- Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi; Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Olivia Keiser
- Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland
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Kim MH, Zhou A, Mazenga A, Ahmed S, Markham C, Zomba G, Simon K, Kazembe PN, Abrams EJ. Why Did I Stop? Barriers and Facilitators to Uptake and Adherence to ART in Option B+ HIV Care in Lilongwe, Malawi. PLoS One 2016; 11:e0149527. [PMID: 26901563 PMCID: PMC4762691 DOI: 10.1371/journal.pone.0149527] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/02/2016] [Indexed: 01/11/2023] Open
Abstract
Causes for loss-to-follow-up, including early refusals of and stopping antiretroviral therapy (ART), in Malawi's Option B+ program are poorly understood. This study examines the main barriers and facilitators to uptake and adherence to ART under Option B+. In depth interviews were conducted with HIV-infected women who were pregnant or postpartum in Lilongwe, Malawi (N = 65). Study participants included women who refused ART initiation (N = 10), initiated ART and then stopped (N = 26), and those who initiated ART and remained on treatment (N = 29). The barriers to ART initiation were varied and included concerns about partner support, feeling healthy, and needing time to think. The main reasons for stopping ART included side effects and lack of partner support. A substantial number of women started ART after initially refusing or stopping ART. There were several facilitators for re-starting ART, including encouragement from community health workers, side effects subsiding, decline in health, change in partner, and fear of future sickness. Amongst those who remained on ART, desire to prevent transmission and improve health were the most influential facilitators. Reasons for refusing and stopping ART were varied. ART-related side effects and feeling healthy were common barriers to ART initiation and adherence. Providing consistent pre-ART counseling, early support for patients experiencing side effects, and targeted efforts to bring women who stop treatment back into care may improve long term health outcomes.
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Affiliation(s)
- Maria H. Kim
- Baylor College of Medicine Department of Pediatrics, Section of Global Health and Retrovirology, Texas Children’s Hospital, Houston, Texas, United States of America
- Baylor College of Medicine—Abbott Fund Children's Clinical Centre of Excellence, Lilongwe, Malawi
| | - Amy Zhou
- Department of Sociology, University of California Los Angeles, Los Angeles, California, United States of America
| | - Alick Mazenga
- Baylor College of Medicine—Abbott Fund Children's Clinical Centre of Excellence, Lilongwe, Malawi
| | - Saeed Ahmed
- Baylor College of Medicine Department of Pediatrics, Section of Global Health and Retrovirology, Texas Children’s Hospital, Houston, Texas, United States of America
- Baylor College of Medicine—Abbott Fund Children's Clinical Centre of Excellence, Lilongwe, Malawi
| | - Christine Markham
- Health Promotion and Behavioral Sciences, The University of Texas School of Public Health, Houston, Texas, United States of America
| | - Gerald Zomba
- HIV Unit, Malawi Ministry of Health, Lilongwe, Malawi
| | - Katie Simon
- Baylor College of Medicine—Abbott Fund Children's Clinical Centre of Excellence, Lilongwe, Malawi
| | - Peter N. Kazembe
- Baylor College of Medicine—Abbott Fund Children's Clinical Centre of Excellence, Lilongwe, Malawi
| | - Elaine J. Abrams
- ICAP, Mailman School of Public Health and College of Physicians & Surgeons, Columbia University, New York, New York, United States of America
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Bhardwaj S, Carter B, Aarons GA, Chi BH. Implementation Research for the Prevention of Mother-to-Child HIV Transmission in Sub-Saharan Africa: Existing Evidence, Current Gaps, and New Opportunities. Curr HIV/AIDS Rep 2016; 12:246-55. [PMID: 25877252 DOI: 10.1007/s11904-015-0260-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Tremendous gains have been made in the prevention of mother-to-child HIV transmission (PMTCT) in sub-Saharan Africa. Ambitious goals for the "virtual elimination" of pediatric HIV appear increasingly feasible, driven by new scientific advances, forward-thinking health policy, and substantial donor investment. To fulfill this promise, however, rapid and effective implementation of evidence-based practices must be brought to scale across a diversity of settings. The discipline of implementation research can facilitate this translation from policy into practice; however, to date, its core principles and frameworks have been inconsistently applied in the field. We reviewed the recent developments in implementation research across each of the four "prongs" of a comprehensive PMTCT approach. While significant progress continues to be made, a greater emphasis on context, fidelity, and scalability-in the design and dissemination of study results-would greatly enhance current efforts and provide the necessary foundation for future evidence-based programs.
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Narasimhan M, Loutfy M, Khosla R, Bras M. Sexual and reproductive health and human rights of women living with HIV. J Int AIDS Soc 2015; 18:20834. [PMID: 28326129 PMCID: PMC4813610 DOI: 10.7448/ias.18.6.20834] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Addressing gender inequalities to improve the sexual and reproductive health and wellbeing of women living with HIV. J Int AIDS Soc 2015; 18:20302. [PMID: 26643464 PMCID: PMC4672401 DOI: 10.7448/ias.18.6.20302] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 09/11/2015] [Accepted: 09/22/2015] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Globally, women constitute 50% of all persons living with HIV. Gender inequalities are a key driver of women's vulnerabilities to HIV. This paper looks at how these structural factors shape specific behaviours and outcomes related to the sexual and reproductive health of women living with HIV. DISCUSSION There are several pathways by which gender inequalities shape the sexual and reproductive health and wellbeing of women living with HIV. First, gender norms that privilege men's control over women and violence against women inhibit women's ability to practice safer sex, make reproductive decisions based on their own fertility preferences and disclose their HIV status. Second, women's lack of property and inheritance rights and limited access to formal employment makes them disproportionately vulnerable to food insecurity and its consequences. This includes compromising their adherence to antiretroviral therapy and increasing their vulnerability to transactional sex. Third, with respect to stigma and discrimination, women are more likely to be blamed for bringing HIV into the family, as they are often tested before men. In several settings, healthcare providers violate the reproductive rights of women living with HIV in relation to family planning and in denying them care. Lastly, a number of countries have laws that criminalize HIV transmission, which specifically impact women living with HIV who may be reluctant to disclose because of fears of violence and other negative consequences. CONCLUSIONS Addressing gender inequalities is central to improving the sexual and reproductive health outcomes and more broadly the wellbeing of women living with HIV. Programmes that go beyond a narrow biomedical/clinical approach and address the social and structural context of women's lives can also maximize the benefits of HIV prevention, treatment, care and support.
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Fundamental concerns of women living with HIV around the implementation of Option B+. J Int AIDS Soc 2015; 18:20286. [PMID: 26643459 PMCID: PMC4672458 DOI: 10.7448/ias.18.6.20286] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 09/07/2015] [Accepted: 09/22/2015] [Indexed: 11/29/2022] Open
Abstract
Introduction In 2011, the Global Plan towards the Elimination of New HIV Infections among Children by 2015 and Keeping Their Mothers Alive was launched to scale up efforts to comprehensively end vertical HIV transmission and support mothers living with HIV in remaining healthy. Amidst excitement around using treatment as prevention, Malawi's Ministry of Health conceived Option B+, a strategy used to prevent vertical transmission by initiating all pregnant and breastfeeding women living with HIV on lifelong antiretroviral therapy, irrespective of CD4 count. In 2013, for programmatic and operational reasons, the WHO officially recommended Option B+ to countries with generalized epidemics, limited access to CD4 testing, limited partner testing, long breastfeeding duration or high fertility rates. Discussion While acknowledging the opportunity to increase treatment access globally and its potential, this commentary reviews the concerns of women living with HIV about human rights, community-based support and other barriers to service uptake and retention in the Option B+ context. Option B+ intensifies many of the pre-existing challenges of HIV prevention and treatment programmes. As women seek comprehensive services to prevent vertical transmission, they can experience various human rights violations, including lack of informed consent, involuntary or coercive HIV testing, limited treatment options, termination of pregnancy or coerced sterilization and pressure to start treatment. Yet, peer and community support strategies can promote treatment readiness, uptake, adherence and lifelong retention in care; reduce stigma and discrimination; and mitigate potential violence stemming from HIV disclosure. Ensuring available and accessible quality care, offering food support and improving linkages to care could increase service uptake and retention. With the heightened focus on interventions to reach pregnant and breastfeeding women living with HIV, a parallel increase in vigilance to secure their health and rights is critical. Conclusion The authors conclude that real progress towards reducing vertical transmission and achieving viral load suppression can only be made by upholding the human rights of women living with HIV, investing in community-based responses, and ensuring universal access to quality healthcare. Only then will the opportunity of accessing lifelong treatment result in improving the health, dignity and lives of women living with HIV, their children and families.
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Pintye J, Ngure K, Curran K, Vusha S, Mugo N, Celum C, Baeten JM, Heffron R. Fertility Decision-Making Among Kenyan HIV-Serodiscordant Couples Who Recently Conceived: Implications for Safer Conception Planning. AIDS Patient Care STDS 2015; 29:510-6. [PMID: 26301703 DOI: 10.1089/apc.2015.0063] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
HIV-serodiscordant couples often choose to attempt pregnancy despite their HIV transmission risk. Optimizing delivery of HIV risk reduction strategies during peri-conception periods (i.e., safer conception) requires understanding how HIV-serodiscordant couples approach fertility decisions. We conducted 36 in-depth individual interviews with male and female partners of Kenyan heterosexual HIV-serodiscordant couples who recently conceived. Transcripts were analyzed by gender and HIV serostatus using open coding. Matrices were used to identify patterns and emerging themes. Most participants expressed acceptance of being in an HIV-serodiscordant couple and affirmed their resilience to live with serodiscordance and achieve their fertility goals. Overall, while the goal for childbearing was unchanged, conception became an urgent desire so that both partners could experience childrearing together while the HIV-infected partner was still healthy. Children also add value to the relationship, and multiple children were a commonly expressed desire. Couples' desires dominated those of individual partners in fertility decision-making, but male preferences were more influential when the individual desires differed. Values and preferences of the couple as a unit may mediate fertility decision-making in HIV-discordant couples. Thus, it is important that safer conception programs include both partners when appropriate and consider the relationship context during risk reduction counseling and when recommending risk reduction interventions.
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Affiliation(s)
- Jillian Pintye
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Nursing, University of Washington, Seattle, Washington
| | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, Washington
- College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | - Kathryn Curran
- Department of Global Health, University of Washington, Seattle, Washington
| | - Sophie Vusha
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, Washington
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
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Khanna AS, Roberts ST, Cassels S, Ying R, John-Stewart G, Goodreau SM, Baeten JM, Murnane PM, Celum C, Barnabas RV. Estimating PMTCT's Impact on Heterosexual HIV Transmission: A Mathematical Modeling Analysis. PLoS One 2015; 10:e0134271. [PMID: 26262889 PMCID: PMC4532442 DOI: 10.1371/journal.pone.0134271] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 07/08/2015] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Prevention of mother-to-child HIV transmission (PMTCT) strategies include combined short-course antiretrovirals during pregnancy (Option A), triple-drug antiretroviral treament (ART) during pregnancy and breastfeeding (Option B), or lifelong ART (Option B+). The WHO also recommends ART for HIV treatment and prevention of sexual transmission of HIV. The impact of PMTCT strategies on prevention of sexual HIV transmission of HIV is not known. We estimated the population-level impact of PMTCT interventions on heterosexual HIV transmission in southwestern Uganda and KwaZulu-Natal, South Africa, two regions with different HIV prevalence and fertility rates. MATERIALS AND METHODS We constructed and validated dynamic, stochastic, network-based HIV transmission models for each region. PMTCT Options A, B, and B+ were simulated over ten years under three scenarios: 1) current ART and PMTCT coverage, 2) current ART and high PMTCT coverage, and 3) high ART and PMTCT coverage. We compared adult HIV incidence after ten years of each intervention to Option A (and current ART) at current coverage. RESULTS At current coverage, Options B and B+ reduced heterosexual HIV incidence by about 5% and 15%, respectively, in both countries. With current ART and high PMTCT coverage, Option B+ reduced HIV incidence by 35% in Uganda and 19% in South Africa, while Option B had smaller, but meaningful, reductions. The greatest reductions in HIV incidence were achieved with high ART and PMTCT coverage. In this scenario, all PMTCT strategies yielded similar results. DISCUSSION Implementation of Options B/B+ reduces adult HIV incidence, with greater effect (relative to Option A at current levels) in Uganda than South Africa. These results are likely driven by Uganda's higher fertility rates.
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Affiliation(s)
- Aditya S. Khanna
- Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Sarah T. Roberts
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Susan Cassels
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Geography, University of California, Santa Barbara, California, United States of America
| | - Roger Ying
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
| | - Steven M. Goodreau
- Department of Anthropology, University of Washington, Seattle, Washington, United States of America
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Pamela M. Murnane
- College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Ruanne V. Barnabas
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
- Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
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Manyahi J, Jullu BS, Abuya MI, Juma J, Ndayongeje J, Kilama B, Sambu V, Nondi J, Rabiel B, Somi G, Matee MI. Prevalence of HIV and syphilis infections among pregnant women attending antenatal clinics in Tanzania, 2011. BMC Public Health 2015; 15:501. [PMID: 25994129 PMCID: PMC4492104 DOI: 10.1186/s12889-015-1848-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 05/18/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The occurrence of HIV-1 and syphilis infections during pregnancy poses major health risks to the foetus due to mother-to-child transmission. We conducted surveillance of HIV and syphilis infections among pregnant women attending antenatal clinics (ANCs) in Mainland Tanzania in 2011. METHODS This surveillance was carried out in 133 ANCs selected from 21 regions in Tanzania. In each region, six ANC sites were selected, with urban, semi-urban, and rural areas contributing two each. All pregnant women who were attending selected sentinel ANC sites for the first time at any pregnancy between September and December 2011 were enrolled. Serial ELISA assays were performed to detect HIV infection in an unlinked anonymous manner using dried blood spot (DBS) after routine syphilis testing. Data analysis was conducted using Stata v.12 software. RESULTS A total of 39,698 pregnant women representing 2.4 % of all pregnant women (1.68 million) attending ANCs in the Mainland Tanzania were enrolled. The overall HIV prevalence was found to be 5.6 % (95 % CI: 5.4-5.8 %). The risk for HIV infection was significantly higher among women aged 25-34 (cOR = 1.97, 95 % CI: 1.79-2.16; p < 0.05), older than 35 years (cOR = 1.88, 95 % CI: 1.62-2.17; p < 0.05) and those having 1-2 and 3-4 previous pregnancies. HIV infection was less prevalent among women attending rural ANC clinics (cOR = 0.46, 95 % CI 0.4-0.52; p < 0.05). The overall syphilis prevalence was 2.5 % (95 % CI: 2.3, 3.6). The risk for syphilis infection was significantly higher among women attending semi-urban and rural clinics and those having 3-4, and 5 previous pregnancies (p < 0.05). Marital status and level of education were not statistically significant with either of the two infections. HIV and syphilis co-infections occurred in 109 of 38,928 (0.3 %). CONCLUSION The overall prevalence of HIV infection (5.6 %) and syphilis (2.5 %) found among pregnant women attending ANC clinics in Tanzania calls for further strengthening of current intervention measures, which include scaling up the integration of prevention of mother to child transmission (PMTCT) services in Reproductive and Child Health (RCH) clinics.
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Affiliation(s)
- Joel Manyahi
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | - Boniphace S Jullu
- St. Francis University College of Health and Allied Sciences, Ifakara, Tanzania.
| | | | - James Juma
- National AIDS Control Programme, Dar es Salaam, Tanzania.
| | | | - Bonita Kilama
- National AIDS Control Programme, Dar es Salaam, Tanzania.
| | - Veryeh Sambu
- National AIDS Control Programme, Dar es Salaam, Tanzania.
| | - Josef Nondi
- National AIDS Control Programme, Dar es Salaam, Tanzania.
| | - Bernard Rabiel
- National AIDS Control Programme, Dar es Salaam, Tanzania.
| | - Geoffrey Somi
- National AIDS Control Programme, Dar es Salaam, Tanzania.
| | - Mecky I Matee
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
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An SJ, George AS, LeFevre A, Mpembeni R, Mosha I, Mohan D, Yang A, Chebet J, Lipingu C, Killewo J, Winch P, Baqui AH, Kilewo C. Program synergies and social relations: implications of integrating HIV testing and counselling into maternal health care on care seeking. BMC Public Health 2015; 15:24. [PMID: 25603914 PMCID: PMC4311416 DOI: 10.1186/s12889-014-1336-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 12/22/2014] [Indexed: 11/18/2022] Open
Abstract
Background Women and children in sub-Saharan Africa bear a disproportionate burden of HIV/AIDS. Integration of HIV with maternal and child services aims to reduce the impact of HIV/AIDS. To assess the potential gains and risks of such integration, this paper considers pregnant women’s and providers’ perceptions about the effects of integrated HIV testing and counselling on care seeking by pregnant women during antenatal care in Tanzania. Methods From a larger evaluation of an integrated maternal and newborn health care program in Morogoro, Tanzania, this analysis included a subset of information from 203 observations of antenatal care and interviews with 57 providers and 190 pregnant women from 18 public health centers in rural and peri-urban settings. Qualitative data were analyzed manually and with Atlas.ti using a framework approach, and quantitative data of respondents’ demographic information were analyzed with Stata 12.0. Results Perceptions of integrating HIV testing with routine antenatal care from women and health providers were generally positive. Respondents felt that integration increased coverage of HIV testing, particularly among difficult-to-reach populations, and improved convenience, efficiency, and confidentiality for women while reducing stigma. Pregnant women believed that early detection of HIV protected their own health and that of their children. Despite these positive views, challenges remained. Providers and women perceived opt out HIV testing and counselling during antenatal services to be compulsory. A sense of powerlessness and anxiety pervaded some women’s responses, reflecting the unequal relations, lack of supportive communications and breaches in confidentiality between women and providers. Lastly, stigma surrounding HIV was reported to lead some women to discontinue services or seek care through other access points in the health system. Conclusion While providers and pregnant women view program synergies from integrating HIV services into antenatal care positively, lack of supportive provider-patient relationships, lack of trust resulting from harsh treatment or breaches in confidentiality, and stigma still inhibit women’s care seeking. As countries continue rollout of Option B+, social relations between patients and providers must be understood and addressed to ensure that integrated delivery of HIV counselling and services encourages women’s care seeking in order to improve maternal and child health.
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Affiliation(s)
- Selena J An
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA.
| | - Asha S George
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA.
| | - Amnesty LeFevre
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA.
| | - Rose Mpembeni
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, PO Box 65015, Dar es Salaam, Tanzania.
| | - Idda Mosha
- Department of Behavioural Sciences, Muhimbili University of Health and Allied Sciences, PO Box 65015, Dar es Salaam, Tanzania.
| | - Diwakar Mohan
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA.
| | - Ann Yang
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA.
| | - Joy Chebet
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA.
| | | | - Japhet Killewo
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, PO Box 65015, Dar es Salaam, Tanzania.
| | - Peter Winch
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA.
| | - Abdullah H Baqui
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA.
| | - Charles Kilewo
- Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, PO Box 65015, Dar es Salaam, Tanzania.
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