Understanding women's uptake and adherence in Option B+ for prevention of mother-to-child HIV transmission in Papua, Indonesia: A qualitative study

A prospective observational cohort study of HIV infection in Indonesia: baseline characteristics and one-year mortality

INTRODUCTION

The incidence rate of newly diagnosed HIV infection in Indonesia decreased from 21 per 100,000 in 2011 to 10 per 100,000 in 2021. Despite this progress, AIDS-related deaths among people living with HIV (PLWH) increased from 3.4% in 2010 to 4.8% in 2020. Determining risk factors for mortality may identify areas to intervene and reduce mortality.

METHODS

A multicenter, prospective, observational cohort study of HIV infection, coinfections, and comorbidities (INA-PROACTIVE) was carried out at 19 hospitals across major islands in Indonesia. The study enrolled PLWH from 2018-2020 and followed them for 3 years. For this analysis, PLWH ≥ 18 years old with one year of follow-up data were included. Cox regression was used to identify variables at enrollment that correlated with one-year mortality.

RESULTS

Among the 4,050 PLWH analysed in the study, 68.8% were male, 53.5% acquired HIV through heterosexual transmission, 92.4% were on antiretroviral treatment (ART) at enrollment, and 72.4% had an undetectable viral load. At one year, 115 (2.8%) had died. Detectable viremia at enrollment was significantly associated with mortality, with the risk increasing as the viral load (VL) category increased (adjusted hazard ratio [aHR] 4.47, 95% CI: 1.47-13.56 for VL 50 to < 1,000 copies/mL; aHR 7.88, 95% CI: 2.80-22.20 for VL 1,000 to 10,000 copies/mL; and aHR 18.33, 95% CI: 7.94-42.34 for VL > 10,000 copies/mL; compared to VL < 50 copies/mL). Other factors at enrollment significantly associated with mortality were a CD4 + count < 200 (aHR 8.02, 95% CI: 2.69-23.86; compared to ≥ 350), age 40-49 years (aHR 2.19, 95% CI 1.23-3.87; compared to 18-29 years) and being underweight (aHR 1.84, 95% CI: 1.18-2.85; compared to normal weight).

CONCLUSIONS

Among predominantly treatment-experienced PLWH, detectable viremia and continued immunosuppression were significantly associated with one-year mortality. This study highlights the importance of ART with complete viral suppression as well as immune recovery to prevent mortality.

TRIAL REGISTRATION

Clinical Trial Number: NCT03663920, registration date: 4 January 2018.

"I'm in the Care Orbit": Unveiling the Enabling Context of the HIV Care Continuum in People Living With HIV

This study aimed to explore the enabling context of the HIV care continuum as perceived by people living with HIV and healthcare professionals. This qualitative study involved in-depth individual interviews with eight people living with HIV and group interviews with seven nurses and physicians. These interviews took place between March 5, 2021, and July 13, 2022. Thematic analysis was conducted. The main themes that emerged included "network of support and systems," "personal gains from the care continuum," "continuity and practicality of healthcare services," "presence of significant other(s)," and "social belonging." These themes were structured within the five levels of the socio-ecological model (system, individual, organizational, interpersonal, and community levels), and 10 subthemes were identified. With the integration of themes, the enabling context was compared to a "care orbit," indicating that people diagnosed with HIV start treatment at the system level and continue HIV care at other levels. In addition to primary support at the system level, the enabling context also includes individual commitment to care and regular health habits, hospital services, support from significant others, and community culture. Together, the context helps guide people living with HIV into the "orbit" of the care system.

The urgency of now to end HIV vertical transmission for pregnant and breastfeeding women and their children in Asia and the Pacific

The global strategy to #EndAIDS is underpinned by a call to end all inequities and to ensure no-one is left behind; but inequities continue, and people are still being left behind. Despite the advances seen in some populations and in some geographical areas, with ongoing high rates of HIV vertical transmission, ending HIV for pregnant and breastfeeding women and their children must be prioritised urgently. Focused on Asia and the Pacific, the region with the second largest number of people with HIV, in this viewpoint we highlight the heterogenous nature of global and regional success in eliminating vertical transmission of HIV. We highlight the gaps of the HIV care cascades of pregnant and breastfeeding women and their children in the region that we need to address and galvanise increased attention, and resources for to set us on a path to the elimination of HIV vertical transmission or reverse the slow decline in transmission needed to achieve the last mile. We conclude that the time is now: we need action to improve maternal and child health in our regional response to HIV if we are to ensure we end AIDS for all.

Optimization of the vertical transmission prevention program in Guinea: impact of the improvement plan on performance indicators at large-cohort sites

INTRODUCTION

Vertical transmission of HIV remains a major challenge in Guinea, especially, in low-resource rural areas. This paper presents the results of a pilot project designed to enhance the prevention of vertical transmission through a comprehensive improvement plan implemented across 66 large-cohort sites.

METHODS

Data from 66 large-cohort of mother to child transmission prevention (PMTCT) sites from 2019 to 2022 were analysed to compare PMTCT metrics before (2019-2020) and after (2021-2022) the improvement initiative. Key indicators were reviewed, and trends were statistically analysed using Mann‒Whitney tests, with a p value less than 0.05 indicating statistical significance.

RESULTS

The implementation of this strategy significantly increased the antiretroviral therapy rate among HIV-positive pregnant women from 66 to 94%, and full antiretroviral prophylaxis coverage was achieved in infants. However, early infant diagnosis via polymerase chain reaction testing falls short of the national target, highlighting deficiencies in laboratory and specimen transport capacities. The study also revealed regional disparities in the use of PMTCT services.

CONCLUSION

The improvement plan effectively enhanced antiretroviral therapy and prophylaxis use, demonstrating the benefits of structured interventions and capacity development. Despite improvements, challenges such as insufficient polymerase chain reaction (PCR) testing and uneven access to services remain. Future initiatives should aim to equip PMTCT sites with essential resources and promote community-driven health-seeking behaviours in underserved areas.

Level of adherence to option B+ program and associated factors among HIV-positive women in Ethiopia: A systematic review and meta-analysis

BACKGROUND

Despite policy initiatives and strategic measures highly focused on preventing mother-to-child transmission through the implementation of the Option B+ program, adherence to the treatment is still challenging. The level of adherence and determinants of Option B+ program utilization reported by different studies were highly inconsistent in Ethiopia. Hence, this systematic review and meta-analysis aimed to estimate the pooled prevalence of adherence to the Option B+ program and its predictors among HIV-positive women in Ethiopia.

METHODS

PubMed, Google Scholar, EMBASE, HINAR, Scopus, and Web of Sciences were searched for published articles from March 2010 to March 2022. The pooled prevalence of adherence was estimated using a weighted DerSimonian-Laird random effect model. The I2 statistics was used to identify the degree of heterogeneity. Publication bias was also assessed using the funnel plot and Egger's regression test.

RESULTS

A total of 15 studies were included. The pooled estimate of the option B+ program among HIV-positive women in Ethiopia was 81.58% (95% CI: 77.33-85.84). Getting social and financial support (AOR = 3.73, 95% CI: 2.12, 6.58), disclosure of HIV status to partners (AOR = 2.05, 95% CI: 1.75, 2.41), time to reach a health facility (AOR = 0.33, 95% CI: 0.16, 0.67), receiving counseling on drug side effects (AOR = 4.09, 95% CI: 2.74, 6.11), experience of drug side effects (AOR = 0.17, 95% CI: 0.08, 0.36), and knowledge (AOR = 4.73, 95% CI: 2.62, 8.51) were significantly associated with adherence to the Option B+ program.

CONCLUSION

This meta-analysis showed that the level of adherence to the Option B+ program in Ethiopia is lower than the 95% level of adherence planned to be achieved in 2020. Social and financial support, disclosure of HIV status, time to reach the health facility, counseling, drug side effects, and knowledge of PMTCT were significantly associated with option B+ adherence. The findings of this meta-analysis highlight that governmental, non-governmental, and other stakeholders need to design an effective strategy to scale up the level of disclosing one's own HIV status, access health facilities, improve knowledge of PMTCT, and counsel the potential side effects of Option B+ drugs, and advocate the program to reduce the multidimensional burden of HIV/AIDS.

TRIAL REGISTRATION

Prospero registration: CRD42022320947. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022320947.

The Psychosocial Profile of Women Who Defaulted Option B+ HIV Treatment: An Interpretive Phenomenological Analysis Study

Purpose

The study explored the psychosocial profile of women who defaulted Option B+ HIV treatment at Chitungwiza Municipality clinics in Zimbabwe. Option B+ is a strategy to prevent mother-to-child transmission (PMTCT) of HIV to reduce MTCT rate to less than or equal to 5%.

Methods

An interpretive phenomenological analysis (IPA) design was used. Data were collected from 04 September to 12 October 2020 on twelve purposively selected HIV-positive breastfeeding women aged 18 to 40 years, who defaulted Option B+ HIV treatment. Unstructured individual face-to-face interviews were utilised. Data were analysed thematically using the interpretive phenomenological analysis framework for data analysis.

Results

The study findings revealed that participants experienced the following: psychosocial and emotional challenges due to HIV positive results, shown emotional distress and suicidal tendencies which affected their mental health. Their relationship was derailed due to abuse, infidelity, partner's high-risk behaviour and to lack of support stemming from their partners and family members.

Conclusion

Strengthening adherence support interventions and effective counselling on HIV-positive status disclosure and male partner involvement is important for retaining women in care and for improving their quality of life. Comprehensive, integrated, and tailor-made interventions should be adopted. Couple HIV counselling and testing should be encouraged. Psychosocial and mental health should be encouraged. Furthermore, community sensitization, risk reduction behaviour, education on purpose and side effects of ART as well as the benefits of Option B+ to new enrolments should be intensified and strengthened to minimize defaulting of treatment and LTFUP. Vigorous patient tracing and visit reminders help retain women in care.

A Peer-support Mini-counseling Model to Improve Treatment in HIV-positive Pregnant Women in Kupang City, East Nusa Tenggara, Indonesia

OBJECTIVES

Low adherence to antiretroviral (ARV) therapy in pregnant women with human immunodeficiency virus (HIV) increases the risk of virus transmission from mother to newborn. Increasing mothers' knowledge and motivation to access treatment has been identified as a critical factor in prevention. Therefore, this research aimed to explore barriers and enablers in accessing HIV care and treatment services.

METHODS

This research was the first phase of a mixed-method analysis conducted in Kupang, a remote city in East Nusa Tenggara Province, Indonesia. Samples were taken by purposive sampling of 17 people interviewed, consisting of 6 mothers with HIV, 5 peer facilitators, and 6 health workers. Data were collected through semi-structured interviews, focus group discussions, observations, and document review. Inductive thematic analysis was also performed. The existing data were grouped into several themes, then relationships and linkages were drawn from each group of informants.

RESULTS

Barriers to accessing care and treatment were lack of knowledge about the benefits of ARV; stigma from within and the surrounding environment; difficulty in accessing services due to distance, time, and cost; completeness of administration; drugs' side effects; and the quality of health workers and HIV services.

CONCLUSIONS

There was a need for a structured and integrated model of peer support to improve ARV uptake and treatment in pregnant women with HIV. This research identified needs including mini-counseling sessions designed to address psychosocial barriers as an integrated approach to support antenatal care that can effectively assist HIV-positive pregnant women in improving treatment adherence.

Barriers and Facilitators to HIV Treatment Adherence in Indonesia: Perspectives of People Living with HIV and HIV Service Providers

HIV treatment adherence in Indonesia is a major challenge. Although previous studies have demonstrated several barriers and facilitators to adherence, studies providing a comprehensive analysis from both PLHIV and HIV service providers' perspectives are limited, especially in Indonesia. In this qualitative study with 30 people living with HIV on treatment (PLHIV-OT) and 20 HIV service providers (HSPs), we explored, via online interviews, the barriers and facilitators to antiretroviral therapy (ART) adherence using a socioecological approach. Both PLHIV-OT and HSPs reported stigma as a major barrier at each socioecological level, including public stigma at the societal level, stigma in healthcare settings, and self-stigma at the intrapersonal level. Stigma reduction must therefore be prioritized. PLHIV-OT and HSPs also reported support from significant others and HSPs as the foremost facilitators to ART adherence. The enablement of support networks is thus an important key to improved ART adherence. Overall, the societal level and health system barriers to ART adherence should be addressed in order to remove barriers and enhance the facilitators at the subordinate socioecological levels.

Exploring barriers to antiretroviral therapy adherence among pregnant women: A scoping literature review

BACKGROUND

Antiretroviral therapy (ART) is one of the most effective ways of preventing HIV-related maternal mortality. However, the rates of retention in care and long-term adherence remain extremely low.

OBJECTIVE

The aim of this study was to explore barriers to antiretroviral therapy adherence among pregnant women.

SEARCH STRATEGY

The search for articles was conducted using EBSCO Host, PubMed, Google scholar, and Cumulative Index of Nursing and Allied Health Literature (CINAHL).

SELECTION CRITERIA

The studies included were conducted between 2000 and 2020 and covered barriers to antiretroviral therapy.

DATA COLLECTION AND ANALYSIS

Data was collected from 8 selected articles and analyzed using Arksey and O'Malley five stages framework.

MAIN RESULTS

Barriers to antiretroviral therapy adherence included side effects of the therapy and financial constraints limiting access to food, transport, and medication. Other barriers included cultural and religious factors, lack of spouse support, stigma, and discrimination.

CONCLUSION

There is need to support pregnant women undergoing antiretroviral therapy to mitigate barriers associated with the uptake of the therapy.

What influences uptake and early adherence to Option B+ (lifelong antiretroviral therapy among HIV positive pregnant and breastfeeding women) in Central Uganda? A mixed methods study

Background

High uptake and optimal adherence to Option B+ antiretroviral therapy (ART) increase effectiveness in averting mother-to-child transmission of HIV. Option B+ ART uptake, early adherence, and associated factors need to be evaluated in Central Uganda.

Methods

A mixed approaches study was carried out in six health facilities in Masaka, Mityana, and Luwero districts from October 2013 to February 2016. Questionnaires were administered to 507 HIV positive pregnant females seeking antenatal care services. Key informant interviews were conducted with 54 health providers, and in-depth interviews (IDIs) with 57 HIV positive women on Option B+ ART. Quantitative data were analyzed using log-binomial regression model to determine factors associated with optimal adherence (taking at least 95% of the prescribed ART), while thematic analysis was used on qualitative data.

Results

Ninety one percent of women (463/507) received a prescription of life long ART. Of these, 93.3% (432/463) started swallowing their medicines. Overall, 83% of women who received ART prescriptions (310/374) felt they were ready to initiate ART immediately. Main motivating factors to swallow ART among those who received a prescription were women’s personal desire to be healthy (92.3%) and desire to protect their babies (90.6%). Optimal adherence to ART was achieved by 76.8% (315/410). Adherence was higher among females who were ready to start ART (adj. PR = 3.20; 95% CI: 1.15–8.79) and those who had revealed their HIV positive result to someone (adj. PR = 1.23; 95% CI: 1.04–1.46). Facilitators of ART uptake from qualitative findings included adequate counseling, willingness to start, and knowing the benefits of ART. Reasons for refusal to start ART included being unready to start ART, fear to take ART for life, doubt of HIV positive results, and preference for local herbs. Reasons for non-adherence were travelling far away from health facilities, fear of side effects, non-disclosure of HIV results to anyone, and perception that the baby is safe from HIV infection post-delivery.

Conclusions

Uptake of Option B+ ART was very high. However, failure to start swallowing ART and sub-optimal adherence are a major public health concern. Enhancing women’s readiness to start ART and encouraging HIV result revelation could improve ART uptake and adherence.

Prevention of HIV Transmission from Mother to Child: Challenges to the Successful Program Implementation and Practice in Indonesia

INTRODUCTION

The level of human immunodeficiency virus (HIV) transmission from mother to child in Indonesia ranks first worldwide. Newborn babies in Indonesia are at greater risk of experiencing the burden of HIV infection than babies born in other countries.

OBJECTIVES

To explore the full extent of Prevention of Mother to Child Transmission (PMTCT) in South Sulawesi Province in 2020 and to discuss program and policy implications for PMTCT.

METHODS

This is a health system analysis study with a qualitative approach using focus group discussion, in-depth interviews, and observations in primary health centers and hospitals.

RESULTS

There is no local policy and guidelines for PMTCT programs and services; the coverage of HIV testing in pregnant women has not achieved 100% according to the target. There are limitations to human resources in public and private services to conduct the program. The assistance's activities to ensure antiretroviral (ARV) adherence are limited, and HIV-positive women faced stigma and discrimination, not only from the community but also from health workers.

RECOMMENDATIONS

Some recommendations are to improve the HIV test coverage to 100% in pregnant women as well as the coverage and quality of ARV treatment.

Perceptions of and barriers to HIV testing of women in Indonesia

Indonesia’s 2014 health reforms advocated for universal health coverage for all Indonesians. The reforms made provision for integrated human immunodeficiency virus (HIV) programmes, with testing available at community health centres and hospitals for pregnant women and women of childbearing age. The question remains, though, as to whether testing has been effective. This article focuses on barriers women face accessing HIV testing and presents findings from the experiences of 18 HIV-positive women. To triangulate findings, interviews were conducted with 26 health workers, 9 non-governmental organisation workers and 12 HIV stakeholders. The article examines barriers to pregnant women’s access to HIV tests, showing that barriers relate to women not having reproductive health rights. It highlights reproductive rights noted in the Respectful Maternity Care Charter, and violations to them relevant to HIV testing in pregnancy. Five reported rights violations include: women being unable to access information; being unable to make informed decisions; having no right to confidentiality and privacy; experiencing ongoing discrimination; and having no right to timely HIV testing. The failure of Indonesia to protect these rights contributes to women being denied HIV testing. Findings show the need for increased HIV testing services for pregnant women and assert that health personnel and programme policy-makers need to be held accountable for the protection and fulfilment of women’s rights in respect of HIV testing. The findings show that policy makers must make changes to ensure health services improve, health professionals must be better trained, and women’s socio-cultural and political contexts must be considered.

Loss to follow up of pregnant women with HIV and infant HIV outcomes in the prevention of maternal to child transmission of HIV programme in two high-burden provinces in Papua New Guinea: a retrospective clinical audit

INTRODUCTION

Despite early adoption of the WHO guidelines to deliver lifelong antiretroviral (ARV) regimen to pregnant women on HIV diagnosis, the HIV prevention of mother to child transmission programme in Papua New Guinea remains suboptimal. An unacceptable number of babies are infected with HIV and mothers not retained in treatment. This study aimed to describe the characteristics of this programme and to investigate the factors associated with programme performance outcomes.

METHODS

We conducted a retrospective analysis of clinical records of HIV-positive pregnant women at two hospitals providing prevention of mother to child transmission services. All women enrolled in the prevention of mother to child transmission programme during the study period (June 2012-June 2015) were eligible for inclusion. Using logistic regression, we examined the factors associated with maternal loss to follow-up (LTFU) before birth and before infant registration in a paediatric ARV programme.

RESULTS

763 of women had records eligible for inclusion. Demographic and clinical differences existed between women at the two sites. Almost half (45.1%) of the women knew their HIV-positive status prior to the current pregnancy. Multivariate analysis showed that women more likely to be LTFU by the time of birth were younger (adjusted OR (AOR)=2.92, 95% CI 1.16 to 7.63), were newly diagnosed with HIV in the current/most recent pregnancy (AOR=3.50, 95% CI 1.62 to 7.59) and were in an HIV serodiscordant relationship (AOR=2.94, 95% CI 1.11 to 7.84). Factors associated with maternal LTFU before infant registration included being primipara at the time of enrolment (AOR=3.13, 95% CI 1.44 to 6.80) and being newly diagnosed in that current/most recent pregnancy (AOR=2.49, 95% CI 1.31 to 4.73). 6.6% (50 of 763) of exposed infants had a positive HIV DNA test.

CONCLUSIONS

Our study highlighted predictors of LTFU among women. Understanding these correlates at different stages of the programme offers important insights for targets and timing of greater support for retention in care.

The perceived determinants and recommendations by mothers and healthcare professionals on the loss-to-follow-up in Option B+ program and child mortality in the Amhara region, Ethiopia

BACKGROUND

The third United Nations Sustainable Development Goal includes a commitment to end AIDS-related death by 2030. In line with the Goal, Option B+ programs hold a great promise for eliminating vertical transmission of HIV. Option B+ was introduced in 2013 in Ethiopia. The Global Plan identified Ethiopia as one of 22 high priority countries requiring improvement in prevention of mother to child HIV transmission services. Despite HIV treatment being free in Ethiopia, only 59% of children are on treatment. The discrepancies in high uptake of Option B+ and low numbers of children in Ethiopia can be attributed to Loss-to-follow-up, which is estimated from 16 to 80%. While LFTU is expected in the region, no-to-minimal evidence exists on the magnitude and its determinants, which hampers the development of interventions and strategies to reduce LFTU. The purpose of this study is to explore perception of mothers and healthcare providers on determinants of and recommendations to reduce LTFU and HIV exposed infants' mortality.

METHOD

Explorative, descriptive qualitative study conducted in five zones of Amhara region. The sample consisted of mothers enrolled to the option B+ programs at the five referral hospitals PMTCT departments, nurses and midwives working in those departments, and HIV officers in zonal departments. Data were collected in 2019 using in-depth interviews. Data were analyzed using content analysis and deduced to themes.

RESULTS

Overall, nine themes were identified from the interviews. Five themes represented the determinants of LTFU and mortality while four themes addressed the recommendations to reduce LFTU among mothers and their infant mortality. The determinants themes centered on apathy, stigma and discrimination, poor access to services, healthcare providers behavior and attitudes, and social determinants of health. While recommendations themes suggested that improving access, capitalizing on psychosocial support, education and awareness, and empowerment.

CONCLUSIONS

Social and structural issues are major contributors to low retention of mothers and death of children due to HIV. A multi-stakeholder approach, including structural changes, are required to support women and their children to ensure that individuals, communities and country enjoy the full benefits of option B+ and lead to an HIV free generation.

Adherence to Option B+ Care for the Prevention of Mother-to-Child Transmission Among Pregnant Women in Ethiopia

PURPOSE

Even if progressive efforts were made in Ethiopia, half of new HIV infections result from mother-to-child transmission. Limited studies assessed the level and factors of adherence that differ among different populations across the country. So, this study aimed to investigate the level and predictors of adherence to the prevention of mother-to-child transmission (PMTCT) Option B+ care among pregnant women in central Ethiopia.

METHODS

A facility-based cross-sectional study design was conducted to interview 347 HIV positive pregnant women. Using a multistage sampling technique, participants were recruited from twelve health facilities based on probability proportional to the number of clients. The collected data on socio-demographics, healthcare delivery, clinical and individual factors were entered into EpiInfo v7.2.2.6, and further analysis was done using SPSS v23 software. Adherence was measured based on client self-report either as adherent and non-adherent. Bivariate and multivariate logistic regressions were undertaken to see the association between variables. Statistically significant variables were declared using an adjusted odds ratio with a 95% confidence interval.

RESULTS

The overall adherence to option B+ was 80.2% (95% CI: 76.3-84.5%). Time of ART initiation (AOR=3.23; 95% CI: 1.09-6.59), fear of stigma for taking ARV (AOR=5.06; 95% CI: 1.79-10.26), ANC appointment (AOR=4.62; 95% CI: 1.48-6.42), male partner support (AOR=2.23; 95% CI: 1.11-4.50), and counseling (AOR=5.36: 95% CI: 1.00-8.58) were the associated factors with level of adherence.

CONCLUSION

The overall adherence level to Option B+ care in this study was inadequate to suppress the viral load during pregnancy. The result revealed that keeping adherence to ARVs during pregnancy is still challenging. So, all concerned bodies need to give attention to minimize the barriers from the client, environment, and health system perspectives.

<p>Level of Good Adherence on Option B+ PMTCT and Associated Factors Among HIV Positive Pregnant and Lactating Mothers in Public Health Facilities of Ilu Abba Bor and Buno Bedele Zones, Oromia Regional State, Southwestern Ethiopia, 2018</p>

Background

PMTCT programs help safe delivery practices and recommended infant feeding, as well as providing ART for infants exposed to HIV after birth for prevention and effective treatment. PMTCT service helps to reduce about 1.4 million HIV infections among children between 2010 and 2018. This study aimed to assess the good adherence level and associated factors of option B+ PMTCT among HIV-positive pregnant and lactating women in public health facilities of Ilu Abba Bor and Buno Bedele zones, Oromia regional state, Southwestern Ethiopia 2018.

Methodology

Institutional-based cross-sectional study design was implemented to investigate the level of good adherence to option B+ PMTCT and possible predictors. A simple random sampling technique was used to interview a total of 180 mothers using the interviewer-guided questionnaire for data collection. Data were entered into EpiData version 3.1 and analyzed by SPSS version 23.0 statistical software. Descriptive statistics and logistic regression were computed to identify and see the relative effect of predictors on the outcome variable.

Results

In this study, 146 (81.1%) of the study participants had good adherence to PMTCT option B+. Women who received social and financial support from friends, family members, and partners had good adherence to PMTCT option B+ than their counterparts. Similarly, women who disclosed their HIV status to others had good adherence than those who did not expose their status to their friends and parents.

Conclusion and Recommendation

This study identified the overall level of PMTCT option B+ adherence level in the study area to be good compared to the national and some other findings. Providing support and encouraging a woman for disclosing their HV status for partners and families are very important to increase the adherence level of option B+.

Challenges to effective and autonomous genetic testing and counseling for ethno-cultural minorities: a qualitative study

Background

The Arab population in Israel is a minority ethnic group with its own distinct cultural subgroups. Minority populations are known to underutilize genetic tests and counseling services, thereby undermining the effectiveness of these services among such populations. However, the general and culture-specific reasons for this underutilization are not well defined. Moreover, Arab populations and their key cultural-religious subsets (Muslims, Christians, and Druze) do not reside exclusively in Israel, but are rather found as a minority group in many European and North American countries. Therefore, focusing on the Arab population in Israel allows for the examination of attitudes regarding genetic testing and counseling among this globally important ethnic minority population.

Methods

We used a qualitative research method, employing individual interviews with 18 women of childbearing age from three religious subgroups (i.e., Druze, Muslim, and Christian) who reside in the Acre district, along with focus group discussions with healthcare providers (HCPs; 9 nurses and 7 genetic counselors) working in the same geographical district.

Results

A general lack of knowledge regarding the goals and practice of genetic counseling resulting in negative preconceptions of genetic testing was identified amongst all counselees. Counselors’ objective of respecting patient autonomy in decision-making, together with counselees’ misunderstanding of genetic risk data, caused uncertainty, frustration, and distrust. In addition, certain interesting variations were found between the different religious subgroups regarding their attitudes to genetic counseling.

Conclusions

The study highlights the miscommunications between HCPs, particularly counselors from the majority ethno-cultural group, and counselees from a minority ethno-cultural group. The need for nuanced understanding of the complex perspectives of minority ethno-cultural groups is also emphasized. Such an understanding may enhance the effectiveness of genetic testing and counseling among the Arab minority group while also genuinely empowering the personal autonomy of counselees from this minority group in Israel and other countries.

Pregnant women's retention and associated health facility characteristics in the prevention of mother-to-child HIV transmission in Indonesia: cross-sectional study

OBJECTIVES

Despite the national effort to integrate the Prevention of Mother-to-Child Transmission (PMTCT) programme into antenatal care clinics in Indonesia, the rate of mother-to-child HIV transmission remains high. This national study was conducted to describe PMTCT programme performance and to identify health facility characteristics associated with this performance in order to inform programme planning and policy development.

DESIGN

A retrospective cross-sectional study in December 2017.

SETTING

All health facilities providing PMTCT programmes in Indonesia.

PARTICIPANTS

All health facilities registering at least one woman in antenatal care in 2017.

INTERVENTION

PMTCT data extraction from the national reporting system on HIV/AIDS and government reports.

OUTCOMES

Women retention in the PMTCT programme for at least 3 months and associated health facility characteristics.

RESULTS

A total of 373 health facilities registering 6502 HIV-positive women in antenatal care were included in the analysis. One-third of women (2099) never started antiretroviral treatment. Of the 4403 women who started, 2610 (57%) were retained; 462 (10%) were not retained; and the retention status of 1252 (28%) women referred out of the health facilities was unknown. Compared with primary health centres, hospitals were more likely to retain women (OR=2.88, 95% CI 2.19 to 3.79). The odds of retention were higher in hospital types A and B (OR=3.89, 95% CI 3.19 to 4.76), located within concentrated HIV epidemic areas (OR=2.09, 95% CI 1.83 to 2.38) and a high-priority area for the HIV programme (OR=1.83, 95% CI 1.60 to 2.09). We observed no differential retention between women who initiated PMTCT under different options (B+/non-B+).

CONCLUSIONS

We observed low retention of HIV-positive pregnant women in the PMTCT programme in Indonesia in 2017. Additional efforts are needed to improve women's retention in the PMTCT programme. Retention could be increased through the delivery of PMTCT programmes by replicating strategies implemented at hospital types A and B located in concentrated HIV epidemic areas where an HIV programme is a high priority.

Im/moral healthcare: HIV and universal health coverage in Indonesia

In 2014, Indonesia reinvigorated its commitment to the provision of a universal health care system by introducing the National Health Insurance Program (Jaminan Kesehatan Nasional, JKN), with the aim of increasing access to health care for all sectors of society. A key question that emerges in the current climate is: how can Indonesia ensure people can access HIV health care? This question is critically important given Indonesia is on the verge of passing a law criminalising all sex outside of marriage. If passed, anyone presenting with HIV will be suspected ipso facto of involvement in criminal activity (e.g. them or their partner having sex outside of marriage and/or using intravenous drugs). In this environment, preventing transmission of HIV from mother to child becomes more difficult. In exploring these issues, we argue that, in a time of populist morality, Indonesia must give significant attention to how universal health coverage can prevent HIV transmission, particularly from mother to child. We offer three key strategies for Indonesia to implement in this regard: removing health care provision from a moral framework; de-idealising the category of woman; and repositioning shame and stigma around HIV.

"I think this is the only challenge… the stigma" Stakeholder perceptions about barriers to Antenatal care (ANC) and Prevention of mother-to-child transmission (PMTCT) uptake in Kano state, Nigeria

Background

Despite the progress made so far in reducing mother-to-child transmission (MTCT), Nigeria still contributes significantly to the global burden of new pediatric HIV infections. The elimination target for MTCT has not been reached and the decline in new infections among all Global Plan countries from 2009 to 2015 was lowest in Nigeria. This qualitative study explores the barriers to uptake of prevention of mother-to-child transmission (PMTCT) intervention in Kano, the second most populous state in Nigeria.

Methods

Key informant interviews (KIIs) were conducted among twelve stakeholders who were purposively selected based on their knowledge and involvement in PMTCT program activities in the state. The KII guide explored the status and challenges of PMTCT uptake in Kano state. Qualitative data analysis was managed using NVIVO 11 software and themes were analyzed using thematic analysis.

Results

We found that the key barriers to uptake of PMTCT identified by stakeholders cut across the domains of the socio-ecological model. These include—fear of stigma associated with being seen accessing HIV related services, low male partner involvement, socio-cultural beliefs about the dangers of hospital-based delivery, poor attitude of health workers, distance/cost to facilities, issues with availability of HIV test kits and poor organization of health services.

Conclusion

The implementation of effective PMTCT programs would require innovative strategies that leverage improvement of Antenatal care (ANC) uptake as an entry point for PMTCT. In addition, sustaining engagement in care requires creating a supportive stigma-free environment in the community as well as spousal support to ensure women can navigate the socio-cultural barriers that limit access to health services.

Perceptions of Community and Clinic-Based Adherence Clubs for Patients Stable on Antiretroviral Treatment: A Mixed Methods Study

Adherence clubs for patients stable on antiretroviral treatment (ART) offer decongestion of clinics and task-shifting, improved adherence and retention in care. Findings on patient acceptability by club location (in the clinic vs. the community) are limited. This was a mixed-methods study set within a randomized controlled trial of community versus clinic-based adherence clubs for retention in care at Witkoppen Health and Welfare Centre in Johannesburg, South Africa. Participants were surveyed on preferences for adherence club-based care (e.g. location, convenience). We conducted in-depth interviews (IDIs) with 36 participants, and surveyed 568 participants: 49% in community-based clubs and 51% in clinic-based clubs. Participants in both arms favorably rated adherence clubs. Almost all (95%) in clinic-based clubs would recommend them to a friend, while fewer (88% in community-based club participants would do so (p = 0.004). Participants found clubs promoted social support, and were convenient and time-saving, though concerns around stigma and access to other health care were noted within community-based clubs. Adherence clubs are a highly acceptable form of differentiated care for stable ART patients. These data indicate that clinic-based clubs may be preferred above community-based clubs, potentially for reasons of stigma and access to additional health care services.

Incidence and predictors of lost to follow-up among women under Option B+ PMTCT program in western Ethiopia: a retrospective follow-up study

Objective

Although Ethiopia has been implementing Option B+ program, LTFU of women from the Option B+ program is one of the challenges that minimizes its implementation. Thus, this study assessed the incidence and predictors of LTFU among women under Option B+ PMTCT program in western Ethiopia. An institution-based retrospective follow-up study was conducted. A cox proportional hazards regression model was fitted to identify predictors of LTFU. A Hazard ratios with 95% confidence CI was computed and all predictors that were associated with the outcome variable at p-value ≤ 0.05 in the multivariable cox proportional hazards were declared as a significance predictor of the outcome.

Results

A total of 330 women were followed for a mean follow up time of 16.9 (± 7.6) months. An overall incidence rate of LTFU was 9/1000 person-months. Women’s educational status, residence, HIV-disclosure status, the status of women at enrollment, previous history of HIV and ART adherence were significant predictors of LTFU. The incidence of LTFU from Option B+ PMTCT is lower as compared to evidence from sub-Saharan African and strengthening linkage and referral system between clinics as well as establishing appropriates tracing mechanisms would retain pregnant women in the program.

"I do all I can but I still fail them": Health system barriers to providing Option B+ to pregnant and lactating women in Malawi

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.

Health Provider Perspectives of Health Facility Preparedness and Organization in Implementation of Option B+ among Pregnant and Lactating Women in Central Uganda: A Qualitative Study

INTRODUCTION

Uganda adopted Option B+ for prevention of mother-to-child transmission (PMTCT) of HIV in 2012. However, there is limited data on preparedness and organization of Option B+ services. These data are critical in informing PMTCT programs and provision of universal antiretroviral therapy (ART) for all populations. This study explored health providers' experiences of preparedness and organization of Option B+ services in Central Uganda.

METHODS

Key informant interviews with 54 health providers from 6 health facilities in 3 districts were conducted. Thematic approach was employed to analyze data.

RESULTS

Themes identified on preparedness were training of frontline health providers and provision of Option B+ guidelines, supervision and mentorship, and provision of essential medicines and medical health supplies, whereas those concerning organization were HIV counseling and testing, ART initiation, follow-up, and patient support mechanisms. Innovations like use of expert clients, assessing women's readiness to start Option B+, and retaining women in antenatal care clinic depending on the need are important in provision of Option B+.

CONCLUSION

This study provides insights into preparedness and organization of Option B+ services which are important in provision of Option B+ and universal ART for all populations. Research around models of follow-up is recommended.

"I Was Not Told That I Still Have The Virus": Perceptions of Utilization of Option B+ Services at a Health Center in Malawi

Utilization of the prevention of mother-to-child transmission of HIV (PMTCT) services remains a challenge as losses to follow-up are substantial. This study explored factors that influence adherence to maternal antiretroviral (ARV) medications among PMTCT mothers in Malawi. We conducted a descriptive qualitative study from September 2016 to May 2017 using purposive sampling among 16 PMTCT mothers and 4 key informant interviews with health-care workers. Data were audio-recorded and analyzed thematically. The factors that influence adherence to maternal ARV medications include the quality of PMTCT services and social support. Factors that impede adherence include suboptimal counseling women receive on ARV medications, cost of travel, and conflicting advice from religious institutions. Adherence to maternal ARV medications will require the use of existing social support systems in a woman's life as a platform for delivery of the drugs while also maintaining continued and comprehensive counseling on the benefits of maternal ARV medications.