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Mupambireyi Z, Cowan FM, Chappell E, Chimwaza A, Manika N, Wedderburn CJ, Gannon H, Gibb T, Heys M, Fitzgerald F, Chimhuya S, Gibb D, Ford D, Mushavi A, Bwakura-Dangarembizi M. "Getting pregnant during COVID-19 was a big risk because getting help from the clinic was not easy": COVID-19 experiences of women and healthcare providers in Harare, Zimbabwe. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002317. [PMID: 38190418 PMCID: PMC10773929 DOI: 10.1371/journal.pgph.0002317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 12/04/2023] [Indexed: 01/10/2024]
Abstract
The COVID-19 pandemic and associated measures may have disrupted delivery of maternal and neonatal health services and reversed the progress made towards dual elimination of mother-to-child transmission of HIV and syphilis in Zimbabwe. This qualitative study explores the impact of the pandemic on the provision and uptake of prevention of mother-to-child transmission (PMTCT) services from the perspectives of women and maternal healthcare providers. Longitudinal in-depth interviews were conducted with 20 pregnant and breastfeeding women aged 20-39 years living with HIV and 20 healthcare workers in two maternity polyclinics in low-income suburbs of Harare, Zimbabwe. Semi-structured interviews were held after the second and third waves of COVID-19 in March and November 2021, respectively. Data were analysed using a modified grounded theory approach. While eight antenatal care contacts are recommended by Zimbabwe's Ministry of Health and Child Care, women reported only being able to access two contacts. Although HIV testing, antiretroviral therapy (ART) refills and syphilis screening services were accessible at first contact, other services such as HIV-viral load monitoring and enhanced adherence counselling were not available for those on ART. Closure of clinics and shortened operating hours during the second COVID-19 wave resulted in more antenatal bookings occurring later during pregnancy and more home deliveries. Six of the 20 (33%) interviewed women reported giving birth at home, assisted by untrained traditional midwives as clinics were closed. Babies delivered at home missed ART prophylaxis and HIV testing at birth despite being HIV-exposed. Although women faced multiple challenges, they continued to attempt to access services after delivery. These findings underline the importance of investing in robust health systems that can respond to emergency situations to ensure continuity of essential HIV prevention, treatment, and care services.
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Affiliation(s)
- Zivai Mupambireyi
- Department of Children and Adolescents Centre for Sexual Health HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
| | - Frances M. Cowan
- Department of Children and Adolescents Centre for Sexual Health HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Elizabeth Chappell
- Medical Research Council (MRC) Clinical Trials Unit at University College London, London, United Kingdom
| | - Anesu Chimwaza
- Department of AIDS/Tuberculosis, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Ngoni Manika
- Department of AIDS/Tuberculosis, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Catherine J. Wedderburn
- Medical Research Council (MRC) Clinical Trials Unit at University College London, London, United Kingdom
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Hannah Gannon
- Institute of Child Health, University College London, London, United Kingdom
| | - Tom Gibb
- Picturing Health, London, United Kingdom
| | - Michelle Heys
- Institute of Child Health, University College London, London, United Kingdom
| | - Felicity Fitzgerald
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
| | - Simbarashe Chimhuya
- Department of Child and Adolescent Health, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Diana Gibb
- Medical Research Council (MRC) Clinical Trials Unit at University College London, London, United Kingdom
| | - Deborah Ford
- Medical Research Council (MRC) Clinical Trials Unit at University College London, London, United Kingdom
| | - Angela Mushavi
- Department of AIDS/Tuberculosis, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Mutsa Bwakura-Dangarembizi
- Department of Child and Adolescent Health, Faculty of Medicine and Health Sciences University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
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Giuliano M, Orlando S, Andreotti M, Mthiko B, Mphwere R, Kavalo T, Ciccacci F, Marazzi MC, Floridia M. Maternal retention and early infant HIV diagnosis in a prospective cohort study of HIV-positive women and their children in Malawi. Int J STD AIDS 2023; 34:54-61. [PMID: 36285600 PMCID: PMC10658750 DOI: 10.1177/09564624221136647] [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: 08/03/2022] [Revised: 10/14/2022] [Accepted: 10/17/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Post-partum loss to follow-up and lack of early HIV infant diagnosis (EID) can significantly affect the efficiency of programs for the prevention of mother-to-child transmission. METHODS In a prospective observational study 167 women were enrolled at week 36 of gestation and followed with their infants up to one year after delivery. Retention was defined as the proportion of women who attended the 12 months visit and EID as an HIV PCR test performed within 2 months. Determinants for retention and EID were assessed in univariate analyses and in multivariable logistic regression models. RESULTS Women lost to follow-up (24/167 or 14.4%) had a shorter duration of antiretroviral therapy (ART) at enrolment in comparison to women retained in care (p = 0.025). Lack of EID (occurring in 18.9% of the cases) was directly correlated, although not significantly, with a history of child death (p = 0.071), a higher educational level (p = 0.083), and female infant gender (p = 0.064). CONCLUSIONS Longer duration of ART at enrolment significantly predicted a better post-partum retention, suggesting that specific counselling interventions should be targeted to recent ART initiators. A low proportion of infants did not receive an EID, but predictive factors were difficult to identify.
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Affiliation(s)
- Marina Giuliano
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Stefano Orlando
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Mauro Andreotti
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Bryan Mthiko
- DREAM Program, Community of S. Egidio, Blantyre, Malawi
| | | | - Thom Kavalo
- DREAM Program, Community of S. Egidio, Blantyre, Malawi
| | - Fausto Ciccacci
- UniCamillus, Saint Camillus International University of Health Sciences, Rome, Italy
| | | | - Marco Floridia
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
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Kim E, Jonnalagadda S, Cuervo-Rojas J, Jahn A, Payne D, West C, Ogollah F, Maida A, Kayira D, Nyirenda R, Dobbs T, Patel H, Radin E, Voetsch A, Auld A. Toward elimination of mother-to-child transmission of HIV in Malawi: Findings from the Malawi Population-based HIV Impact Assessment (2015–2016). PLoS One 2022; 17:e0273639. [PMID: 36048781 PMCID: PMC9436140 DOI: 10.1371/journal.pone.0273639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 08/11/2022] [Indexed: 11/23/2022] Open
Abstract
Background Malawi spearheaded the development and implementation of Option B+ for prevention of mother-to-child transmission of HIV (PMTCT), providing life-long ART for all HIV-positive pregnant and breastfeeding women. We used data from the 2015–2016 Malawi Population-based HIV Impact Assessment (MPHIA) to estimate progress toward 90-90-90 targets (90% of those with HIV know their HIV-positive status; of these, 90% are receiving ART; and of these, 90% have viral load suppression [VLS]) for HIV-positive women reporting a live birth in the previous 3 years. Methods MPHIA was a nationally representative household survey; consenting eligible women aged 15–64 years were interviewed on pregnancies and outcomes, including HIV status during their most recent pregnancy, PMTCT uptake, and early infant diagnosis (EID) testing. Descriptive analyses were weighted to account for the complex survey design. Viral load (VL) results were categorized by VLS (<1,000 copies/mL) and undetectable VL (target not detected/below the limit of detection). Results Of the 3,153 women included in our analysis, 371 (10.1%, 95% confidence interval [CI]: 8.8%–11.3%) tested HIV positive in the survey. Most HIV-positive women (84.2%, 95% CI: 79.9%–88.6%) reported knowing their HIV-positive status; of these, 94.9% (95% CI: 91.7%–98.2%) were receiving ART; and of these, 91.2% (95% CI: 87.4%–95.0%) had VLS. Among the 371 HIV-positive women, 76.0% (95% CI: 70.4%–81.7%) had VLS and 66.5% (95% CI: 59.8%–73.2%) had undetectable VL. Among 262 HIV-exposed children, 50.8% (95% CI: 42.8%–58.8%) received EID testing within 2 months of birth, whereas 17.9% (95% CI: 11.9%–23.8%) did not receive EID testing. Of 190 HIV-exposed children with a reported HIV test result, 2.1% (95% CI: 0.0%–4.6%) had positive results. Conclusions MPHIA data demonstrate high PMTCT uptake at a population level. However, our results identify some gaps in VLS in postpartum women and EID testing.
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Affiliation(s)
- Evelyn Kim
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
- * E-mail:
| | - Sasi Jonnalagadda
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Juliana Cuervo-Rojas
- ICAP at Columbia University, New York, NY, United States of America
- Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Andreas Jahn
- Division of HIV and AIDS, Ministry of Health, Government of Malawi, Lilongwe, Malawi
| | - Danielle Payne
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Christine West
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Francis Ogollah
- ICAP at Columbia University, New York, NY, United States of America
| | - Alice Maida
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Dumbani Kayira
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Rose Nyirenda
- Division of HIV and AIDS, Ministry of Health, Government of Malawi, Lilongwe, Malawi
| | - Trudy Dobbs
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Hetal Patel
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Elizabeth Radin
- ICAP at Columbia University, New York, NY, United States of America
| | - Andrew Voetsch
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Andrew Auld
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
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Chimwaza AN, Tweya H, Mugurungi O, Mushavi A, Mukungunugwa S, Sithole N, Nyakura J, Senkoro M, Owiti P, Ncube R, Tapera T, Mandewo W, Edwards JK, Mangombe A, Taramusi I. Early retention among pregnant women on 'Option B + ' in urban and rural Zimbabwe. AIDS Res Ther 2021; 18:10. [PMID: 33794957 PMCID: PMC8015197 DOI: 10.1186/s12981-021-00333-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 03/13/2021] [Indexed: 11/16/2022] Open
Abstract
Background In 2013, the World Health Organisation (WHO) recommended Option B+ as a strategy to prevent mother-to-child transmission (PMTCT) of HIV. In option B+ , lifelong antiretroviral therapy (ART) is offered to all HIV positive pregnant and breastfeeding women to reduce MTCT rate to less than or equal to 5%. Its success depends on retaining women on ART during pregnancy, delivery and breast-feeding period. There is limited data on early retention on ART among pregnant women in Zimbabwe. We therefore assessed early retention among women on Option B + from antenatal care (ANC) until 6 months post ANC booking and at delivery in Bulawayo city and Mazowe rural district of Zimbabwe. Methods We collected data for pregnant women booking for ANC between January and March 2018, comparing early retention among ART naïve women and those already on ART. The two cohorts were followed up for 6 months post ANC booking, and this was done in two districts. Data were collected from routine tools used at facility level which include ANC, delivery and ART registers. The Kaplan-Meier survival analysis was used to estimate retention probabilities at 1, 3 and 6 months post-delivery and for retention at delivery proportions were used. Poisson regression was used to investigate factors associated with non-retention at 6 months post ANC booking. Results A total of 388 women were included in the study with median age of 29 years (IQR: 25–34). Two-thirds booked in their second trimester. Retention at 3 and 6 months post ANC booking was 84% (95% CI 80–88) and 73% (95% CI 69–78) respectively. At delivery 81% (95% CI 76–84) were retained in care, 18% lost-to-follow-up and 1% transferred out. In this study we did not find marital status, gestation age, facility location, ART status at ANC booking, to be associated with loss to follow-up. Conclusion In this study, we found low retention at 3, 6 months and delivery, a threat to elimination of Mother-to-child Transmission of HIV in Zimbabwe. Our findings emphasize the need for enhanced interventions to improve early retention such as post-test counselling, patient tracing and visit reminders.
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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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Reidy W, Nuwagaba-Biribonwoha H, Shongwe S, Sahabo R, Hartsough K, Wu Y, Gachuhi A, Mthethwa-Hleta S, Abrams EJ. Engagement in care among women and their infants lost to follow-up under Option B+ in eSwatini. PLoS One 2019; 14:e0222959. [PMID: 31665137 PMCID: PMC6821080 DOI: 10.1371/journal.pone.0222959] [Citation(s) in RCA: 3] [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: 04/30/2019] [Accepted: 09/10/2019] [Indexed: 11/18/2022] Open
Abstract
Background Universal antiretroviral treatment (ART) for pregnant women with HIV, Option B+, has been adopted widely for prevention of mother-to-child HIV transmission (PMTCT). Some evidence shows high loss to follow-up (LTF) under this model. However, gaps in data systems limit this evidence. We collected additional information for women and infants LTF from Option B+ in Eswatini to assess more accurate outcomes. Methods LTF at 6-months postpartum was assessed using facility data. Additional data was gathered from: 1) the national ART database and paper records; 2) patient tracing; and 3) interviews and abstraction from patient-held records. Engagement in care was defined as any clinic visit within 91 days before or after 6-months postpartum or completion of a documented transfer; or, for those traced but not completing study interviews, visits at 6-months postpartum or later (for infants), or visits within 3-months of tracing (for women). Multivariable loglinear models were used to identify correlates of engagement. Results One-hundred-ninety-four (44.7%) of 434 LTF women had outcomes ascertained, including 122 (62.9%) women engaged in care. Among 510 LTF infants, 265 (52.0%) had ascertained outcomes, including 143 (54.0%) engaged in care, 47 (17.7%) pregnancy losses, and 18 (6.8%) deaths. Seventy-two of 189 live infants (38.1%) with ascertained outcomes had a 6-week early infant diagnostic (EID) test. Among women with ascertained outcomes, gestational age of 20+ weeks (vs. fewer than 20 weeks, aRR 0.80; 95% CI 0.68–0.94) and age 25–29 years (vs. 15–24 years, aRR 0.81; 95% CI 0.67–0.97), were associated with lower engagement; initiating ART after first ANC visit was associated with higher engagement (vs. at first ANC visit, aRR 1.12; 95% CI 1.04–1.21). Among infants with ascertained outcomes, mother not initiating ART was associated with lower engagement (vs. ART at first ANC visit, aRR 0.71; 95% CI 0.54–0.91). Conclusion Substantial numbers of women and infants classified as LTF under Option B+ were engaged in care, though a suboptimal level of 6-week EID testing was observed. These findings highlight a need to improve coverage of routine EID testing, and improve data systems to better capture PMTCT patient outcomes.
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Affiliation(s)
- William Reidy
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, New York, United States of America
- * E-mail:
| | - Harriet Nuwagaba-Biribonwoha
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, New York, United States of America
| | - Siphesihle Shongwe
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Ruben Sahabo
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Kieran Hartsough
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Yingfeng Wu
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Averie Gachuhi
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | | | - Elaine J. Abrams
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, New York, United States of America
- Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, United States of America
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"I do all I can but I still fail them": Health system barriers to providing Option B+ to pregnant and lactating women in Malawi. PLoS One 2019; 14:e0222138. [PMID: 31513684 PMCID: PMC6742345 DOI: 10.1371/journal.pone.0222138] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 08/22/2019] [Indexed: 11/30/2022] Open
Abstract
Malawi’s Option B+ program is based on a ‘test and treat’ strategy that places all HIV-positive pregnant and lactating women on lifelong antiretroviral therapy. The steep increase in patient load placed severe pressure on a health system that has struggled for decades with inadequate supply of health care workers (HCWs) and poor infrastructure. We set out to explore health system barriers to Option B+ by asking HCWs in Malawi about their experiences treating pregnant and lactating women. We observed and conducted semi-structured interviews (SSIs) with 34 HCWs including nine expert clients (ECs) at 14 health facilities across Malawi, then coded and analyzed the data. We found that HCWs implementing Option B+ are so overburdened in Malawi that it reduces their ability to provide quality care to patients, who receive less counseling than they should, wait longer than is reasonable, and have very little privacy. Interventions that increase the number of HCWs and upgrade infrastructure to protect the privacy of HIV-infected pregnant and lactating women and their husbands could increase retention, but facilities will need to be improved to support men who accompany their partners on clinic visits.
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Bengtson AM, Go V, Kumwenda W, Lurie M, Kutengule A, Owino M, Hosseinipour M. "A way of escaping": a qualitative study exploring reasons for clinic transferring and its impact on engagement in care among women in Option B. AIDS Care 2019; 32:72-75. [PMID: 31067986 DOI: 10.1080/09540121.2019.1614521] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Clinic transfers among women in Option B+ are frequent, often undocumented, and may lead to suboptimal engagement in care and HIV outcomes. The reasons women move between HIV clinics are not well understood. We conducted four focus group discussions (FGD) among HIV-infected pregnant women in Option B+ and four FGDs and five in-depth interviews among healthcare workers (HCWs) at two large ART clinics in Lilongwe, Malawi. Mobility and fear of inadvertent HIV disclosure, particularly due to seeing neighbors or acquaintances at a clinic, were key drivers of transferring between HIV clinics. Women were aware of the need to obtain a formal transfer, but in practice this was often not feasible and led women to self-transfer clinics. Self-transferring to a new clinic frequently resulted to re-testing and re-initiating ART and concerns about disruptions in ART. Strategies to monitor women's engagement in HIV care without requiring a formal transfer are urgently needed.
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Affiliation(s)
- Angela M Bengtson
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Vivian Go
- Department of Health Behavior, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | | | - Mark Lurie
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | | | - Michael Owino
- Department of Medicine, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Mina Hosseinipour
- UNC Project-Malawi, Lilongwe, Malawi.,Department of Medicine, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
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Probable antenatal depression at antiretroviral initiation and postpartum viral suppression and engagement in care. AIDS 2018; 32:2827-2833. [PMID: 30234603 DOI: 10.1097/qad.0000000000002025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To estimate the association of probable antenatal depression with postpartum HIV care engagement among pregnant women in Malawi. DESIGN We conducted a prospective cohort study of 299 women who were initiating antiretroviral therapy (ART) through Option B+ at a government antenatal clinic in Malawi. METHODS Probable antenatal depression was assessed on the day of ART initiation with the validated Chichewa version of the Edinburgh Postnatal Depression Scale (EPDS). We estimated crude and adjusted risk differences (RD, aRD) of visit attendance and prevalence differences (PD, aPD) of viral suppression through 12 months post-ART initiation comparing women with versus without probable antenatal depression. RESULTS One in 10 women had probable antenatal depression. Most women were engaged in care through 12 months post-ART initiation: 85% attended all scheduled ART visits, and 81% were in care and virally suppressed. Women with and without probable antenatal depression had a comparable probability of attending all scheduled visits (RD: -0.02; 95% CI -0.16 to 0.12; aRD: -0.04; 95% CI -0.18 to 0.10), and of viral suppression (PD: -0.02; 95% CI -0.17 to 0.13; aPD: -0.01; 95% CI -0.17 to 0.15) in crude and adjusted analyses. CONCLUSION Probable antenatal depression was not associated with engagement in HIV care through 12 months post-ART initiation. In a population with high HIV care engagement, antenatal depression may not impair HIV-related outcomes.
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