Barriers to accessing PMTCT services in a rural area of South Africa

Final HIV status outcome for HIV-exposed infants at 18 months of age in nine states and the Federal Capital Territory, Nigeria

Introduction

While antiretroviral therapy (ART) coverage for pregnant women has undergone steady scale-up, Nigeria’s final mother- to-child transmission of HIV (MTCT) rate remains unacceptably high at 10%. This study aimed to determine final outcomes (MTCT rates) and their correlates among HIV-exposed infants (HEI) in nine states and the Federal Capital Territory, Nigeria.

Methods

This retrospective, cross-sectional study was conducted at 96 primary, secondary and tertiary health facilities supported by the Institute of Human Virology Nigeria. Data was abstracted for a birth cohort of HEI born between October 30, 2014 and April 30, 2015 whose 18–24 month final outcome was assessed by October 30, 2016. Only infants with a six-week first DNA PCR result, and a rapid HIV antibody test result at age 18 to 24 months were included. Multivariate logistic regression (adjusted odds ratios [aORs]) evaluated for predictors of HIV positivity at ≥18 months.

Results

After testing at ≥18 months, 68 (2.8%) of the 2,405 exposed infants in the birth cohort were HIV-positive. After a minimum of 18 months of follow-up, 51 (75%) HIV-positive infants were alive on ART; 7 (10%) had died, 5 (7.3%) were lost to follow-up and 5 (7.3%) were transferred out. Rural maternal residence, lack of maternal ART/ARV prophylaxis, mixed infant feeding and infant birth weight less than 2.5 kg correlated with an HIV-positive status for infant final outcomes.

Conclusion

The final HIV positivity rate of 2.8% is encouraging, but is not population-based. Nevertheless, supported by our findings, we recommend continued programmatic focus on early access to quality prenatal care and maternal ART for pregnant women, especially for women living with HIV in rural areas. Furthermore, implementation of nationwide sensitization and education on six-months’ exclusive infant breastfeeding with concurrent maternal ART should be strengthened and sustained to reduce MTCT rates.

Knowledge, Experience and Perception of Gender-Based Violence Health Services: A Mixed Methods Study on Adolescent Girls and Young Women in Tanzania

Many adolescent girls and young women (AGYW) experience gender-based violence (GBV) in Tanzania and only few seek GBV health services following violence. The objectives of our study are (1) to evaluate knowledge of gender-based violence among AGYW, (2) to explore their perceptions of and experiences with GBV health service quality and (3) to evaluate access to comprehensive GBV services. This study employed an explanatory, sequential mixed methods design in two districts of Dar es Salaam, Tanzania (Kinondoni and Temeke). A quantitative cross-sectional survey among AGYW (n = 403) between 15-24 years old was performed to assess their knowledge of GBV as well as perceptions of and experiences with GBV health services. The quantitative data was complemented by 20 semi-structured in-depth interviews with participants. Out of 403 study participants, more than three quarters (77.9%) had moderate to good knowledge of how GBV is defined and what constitutes gender-based violence. However, few participants (30.7%, n = 124) demonstrated knowledge of GBV health services offered at local health facilities. For example, only 10.7% (n = 43) of participants reported knowledge of forensic evidence collection. Additionally, of 374 participants (93% of total participants) who reported to have received GBV education sessions, only 66% accessed GBV health services (n = 247) and about half of these (52.7%, n = 130) were satisfied with these services. The study indicated that-despite good knowledge about what constituted GBV-knowledge about the roles and availability of GBV health services was limited and utilization of GBV health services remained low. Coordinated actions need to be strengthened to reach AGYW who remain unaware of GBV health services offered at health facilities by improving GBV service quality, bettering interventions aimed at reducing GBV among AGYW in Tanzania, and scaling-up integrated service models, such as GBV one-stop centers.

Prenatal HIV Test Uptake and Its Associated Factors for Prevention of Mother to Child Transmission of HIV in East Africa

Identifying the socioeconomic and structural issues that act as enablers and/or barriers to HIV testing services is critical in combatting HIV/AIDS amongst mothers and children in Africa. In this study, we used a weighted sample of 46,645 women aged 15–49 who gave birth in the two years preceding the survey from the recent DHS dataset of ten East African countries. Multivariable logistic regression was used to investigate the factors associated with prenatal HIV test uptake in East Africa. The overall prenatal HIV test uptake for the prevention of mother-to-child transmission (PMTCT) of HIV was 80.8% (95% CI: 74.5–78.9%) in East Africa, with highest in Rwanda (97.9%, 95% CI: 97.2–98.3%) and lowest in Comoros (17.0%, 95% CI: 13.9–20.7%). Common factors associated with prenatal HIV test service uptake were higher maternal education level (AOR = 1.29; 95% CI: 1.10–1.50 for primary education and AOR = 1.96; 95% CI: 1.53–2.51 for secondary or higher education), higher partner education level (AOR = 1.24; 95% CI: 1.06–1.45 for primary education and AOR = 1.56; 95% CI: 1.26–1.94 for secondary or higher school), women from higher household wealth index (AOR = 1.29; 95% CI: 1.11–1.50 for middle wealth index; AOR = 1.57; 95% CL: 1.17–2.11 for rich wealth index), improved maternal exposure to the media, and increased awareness about MTCT of HIV. However, residents living in rural communities (AOR = 0.66; 95% CI: 0.51–0.85) and travelling long distances to the health facility (AOR = 0.8; 95% CI: 0.69–0.91) were associated with non-use of prenatal HIV test service in East African countries. In each East African country, factors associated with prenatal HIV test uptake for PMTCT varied. In conclusion, the pooled prenatal HIV test uptake for PMTCT of HIV was low in East Africa compared to the global target. Scaling up interventions to improve enablers whilst addressing barriers to the use of prenatal HIV test services are essential to end the HIV/AIDS epidemic in East African countries.

Barriers to the management of children under five exposed to HIV in the rural areas of South Africa

BACKGROUND

South Africa has made enormous progress in reducing mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV), however, MTCT and AIDS related death persist among children particularly in the rural areas. Lack of adherence to health policies and guidelines implementation remain one of the contributory factors to poor management of HIV-exposed children. Hence, the need to deeply explore the complexity of the problems and understand the barriers to the management of HIV exposed children in the rural areas.

OBJECTIVES

To explore and synthesise the barriers to the management of children under 5 years old exposed to HIV in rural areas in South Africa.

METHOD

An integrative literature review was conducted. An electronic search was conducted on several databases. The researchers applied the Boolean ' AND'/'OR' in combination with phrases such as 'HIV infection*', 'HIV transmission', 'HIV-exposed infant*, child*, and neonate*' and 'South Africa*'. Included studies were limited to South Africa, and articles were written in English and published in peer-reviewed journals from 2005 to 2018. Both qualitative and quantitative studies between 2005 and 2018 were utilised.

RESULTS

The findings highlighted that healthcare institution-related barriers, healthcare provider-related barriers, patient-related barriers and Socio-economic-related barriers were the significant barriers to the management of HIV-exposed children in the rural areas.

CONCLUSION

Continuous engagement with all relevant stakeholders should remain a priority in protecting HIV-exposed children. It is evident that there exist gaps in the current implementation of prevention of mother-to-child transmission (PMTCT), especially in rural areas. Therefore, intervention strategies that could improve implementation of PMTCT policy guidelines for HIV-exposed children in rural areas are needed.

Determinants of Male Partner Involvement Towards Prevention of Mother to Child Transmission Service Utilization Among Pregnant Women Who Attended Focused Antenatal Care in Southern Ethiopia

BACKGROUND

Male partner involvement is an important and crucial determinant of prevention of mother to child transmission (PMTCT) of HIV. It creates an opportunity to reverse the transmission of HIV during pregnancy, labor, and breastfeeding. Thus, involving male partners during HIV screening of pregnant mothers at ANC is the key to fight against MTCT of HIV.

OBJECTIVE

This study was designed to assess the magnitude and factors associated with male partner's involvement on PMTCT service utilization among pregnant women who attended focused antenatal care (FANC) in Southern Ethiopia.

METHODS

An institutional-based cross-sectional study was conducted among 420 randomly selected pregnant women who enrolled in PMTCT service at ANC clinics. Pre-tested and structured self-administered questionnaires were used to collect the data. Multiple logistic regression analysis was used to determine the presence of statistically significant associations between the outcome variable and the independent variables with a p-value less than 0.05.

RESULTS

A total of 409 pregnant women who had ANC follow-up have participated in this study. The majority 160 (39.1%) of the participants were in the age group of 25-29 years. The magnitude of male involvement in PMTCT service was 129 (29.8%). Number of ANC visits (3rd visit (AOR=2.36, CI=1.09, 5.10), 4th visit (AOR=3.49, CI=1.65, 7.38), birthplace interest (AOR=3.01, CI=1.16, 7.84), awareness about partner monthly income (AOR=2.17, CI=1.15, 4.11), source of family saving scheme (partner (AOR=2.99, CI=1.39, 6.43), self (AOR=8.59, CI=3.92, 18.82), both (AOR=5.13, CI=2.21, 11.92), maternal perception about the importance of consulting partner before HIV testing (AOR=9.30, CI=2.65, 32.64), and kinds of partner support (psychological (AOR=0.08, CI=0.02, 0.29), financial (AOR=0.33, CI=0.17, 0.68) were found to be significantly associated with male involvement in PMTCT.

CONCLUSION

This study found out that male partner involvement in PMTCT is low. Therefore, improving male partner involvement in PMTCT is recommended for improving maternal FANC service utilization and adherence with notification of their partner and provision of psychological and financial support.

Factors associated with the utilization of antenatal care and prevention of mother-to-child HIV transmission services in Ethiopia: applying a count regression model

BACKGROUND

Prevention of Mother-to-Child HIV Transmission (PMTCT) coverage has been low in Ethiopia and the service has been implemented in a fragmented manner. Solutions to this problem have mainly been sought on the supply-side in the form of improved management and allocation of limited resources. However, this approach largely ignores the demand-side factors associated with low PMTCT coverage in the country. The study assesses the factors associated with the utilization of PMTCT services taking into consideration counts of visits to antenatal care (ANC) services in urban high-HIV prevalence and rural low-HIV prevalence settings in Ethiopia.

METHODS

A multivariate regression model was employed to identify significant factors associated with PMTCT service utilization. Poisson and negative binomial regression models were applied, considering the number of ANC visits as a dependent variable. The explanatory variables were age; educational status; type of occupation; decision-making power in the household; living in proximity to educated people; a neighborhood with good welfare services; location (urban high-HIV prevalence and rural low-HIV prevalence); transportation accessibility; walking distance (in minutes); and household income status. The alpha dispersion test (a) was performed to measure the goodness-of-fit of the model. Significant results were reported at p-values of < 0.05 and < 0.001.

RESULTS

Household income, socio-economic setting (urban high-HIV prevalence and rural low-HIV prevalence) and walking distance (in minutes) had a statistically significant relationship with the number of ANC visits by pregnant women (p < 0.05). A pregnant woman from an urban high-HIV prevalence setting would be expected to make 34% more ANC visits (counts) than her rural low-HIV prevalence counterparts (p < 0.05). Holding other variables constant, a unit increase in household income would increase the expected ANC visits by 0.004%. An increase in walking distance by a unit (a minute) would decrease the number of ANC visits by 0.001(p < 0.001).

CONCLUSION

Long walking distance, low household income and living in a rural setting are the significant factors associated with low PMTCT service utilization. The primary strategies for a holistic policy to improve ANC/PMTCT utilization should thus include improving the geographical accessibility of ANC/PMTCT services, expanding household welfare and paying more attention to remote rural areas.

Water treatment and handwashing practices in rural Kenyan health care facilities and households six years after the installation of portable water stations and hygiene training

Many health care facilities (HCFs) and households in low-and-middle-income countries have inadequate access to water for hygiene and consumption. To address these problems, handwashing and drinking water stations were installed in 53 HCFs with prevention-of-mother-to-child-transmission of HIV programs in Kenya in 2005, and hygiene education was provided to health workers and clinic clients. To assess this program, we selected a random sample of 30 HCFs, observed the percentage of handwashing and drinking water stations that were functional and in use, and after that interviewed health providers and clients about hygiene and water treatment. Results indicated that, six years after implementation, 80.0% of HCFs had at least one functional handwashing station and 83.3% had at least one functional drinking water station. In addition, 60% of HCFs had soap at ≥ one handwashing stations, and 23.3% had ≥ one container with detectable free chlorine. Of 299 clients (mothers with ≥ one child under five), 57.2% demonstrated proper water treatment knowledge, 93.3% reported ever using water treatment products, 16.4% had detectable chlorine residual in stored water, and 89.0% demonstrated proper handwashing technique. Six years after program implementation, although most HCFs had water stations and most clients could demonstrate proper handwashing technique, water stored in most clinics and homes was not treated.

The Achilles' heel of prevention to mother-to-child transmission of HIV: Protocol implementation, uptake, and sustainability

The Joint United Nations Programme on HIV and AIDS proposed to reduce the vertical transmission of HIV from ∼72,200 to ∼8300 newly infected children by 2015 in South Africa (SA). However, cultural, infrastructural, and socio-economic barriers hinder the implementation of the prevention of mother-to-child transmission (PMTCT) protocol, and research on potential solutions to address these barriers in rural areas is particularly limited. This study sought to identify challenges and solutions to the implementation, uptake, and sustainability of the PMTCT protocol in rural SA. Forty-eight qualitative interviews, 12 focus groups discussions (n = 75), and one two-day workshop (n = 32 participants) were conducted with district directors, clinic leaders, staff, and patients from 12 rural clinics. The delivery and uptake of the PMTCT protocol was evaluated using the Consolidated Framework for Implementation Research (CFIR); 15 themes associated with challenges and solutions emerged. Intervention characteristics themes included PMTCT training and HIV serostatus disclosure. Outer-setting themes included facility space, health record management, and staff shortage; inner-setting themes included supply use and availability, staff-patient relationship, and transportation and scheduling. Themes related to characteristics of individuals included staff relationships, initial antenatal care visit, adherence, and culture and stigma. Implementation process themes included patient education, test results delivery, and male involvement. Significant gaps in care were identified in rural areas. Information obtained from participants using the CFIR framework provided valuable insights into solutions to barriers to PMTCT implementation. Continuously assessing and correcting PMTCT protocol implementation, uptake and sustainability appear merited to maximize HIV prevention.

Implementation and Operational Research: Distance From Household to Clinic and Its Association With the Uptake of Prevention of Mother-to-Child HIV Transmission Regimens in Rural Zambia

BACKGROUND

In rural settings, HIV-infected pregnant women often live significant distances from facilities that provide prevention of mother-to-child transmission (PMTCT) services.

METHODS

We offered universal maternal combination antiretroviral regimens in 4 pilot sites in rural Zambia. To evaluate the impact of services, we conducted a household survey in communities surrounding each facility. We collected information about HIV status and antenatal service utilization from women who delivered in the past 2 years. Using household Global Positioning System coordinates collected in the survey, we measured Euclidean (i.e., straight line) distance between individual households and clinics. Multivariable logistic regression and predicted probabilities were used to determine associations between distance and uptake of PMTCT regimens.

RESULTS

From March to December 2011, 390 HIV-infected mothers were surveyed across four communities. Of these, 254 (65%) had household geographical coordinates documented. One hundred sixty-eight women reported use of a PMTCT regimen during pregnancy including 102 who initiated a combination antiretroviral regimen. The probability of PMTCT regimen initiation was the highest within 1.9 km of the facility and gradually declined. Overall, 103 of 145 (71%) who lived within 1.9 km of the facility initiated PMTCT versus 65 of 109 (60%) who lived farther away. For every kilometer increase, the association with PMTCT regimen uptake (adjusted odds ratio: 0.90, 95% confidence interval: 0.82 to 0.99) and combination antiretroviral regimen uptake (adjusted odds ratio: 0.88, 95% confidence interval: 0.80 to 0.97) decreased.

CONCLUSIONS

In this rural African setting, uptake of PMTCT regimens was influenced by distance to health facility. Program models that further decentralize care into remote communities are urgently needed.

Implementation of the national programme for prevention of mother-to-child transmission of HIV: a rapid assessment in Cacadu district, South Africa

To conduct a rapid assessment of the prevention-of-mother-to-child-transmission-of-HIV (PMTCT) programme in two of the three local service areas in Cacadu district, Eastern Cape province, South Africa, we designed an exploratory study using a mixed-methods approach. Quantitative and qualitative data on PMTCT programme implementation were collected in 2008 through a structured assessment at the 44 health facilities implementing the programme in the province. This included in-depth interviews with 11 clinic supervisors, 31 clinic programme coordinators, and 8 hospital/maternity staff members in order to examine their perceived problems and suggestions regarding PMTCT programme implementation; an assessment of the clinic registers and recording systems; a meeting with stakeholders; and one feedback meeting with clinic managers, sub-district management and other stakeholders in regard to the results of the rapid assessment. Overall, most of the national criteria for PMTCT programme implementation were fulfilled across the health facilities. However, shortcomings were found relating to health policy, health services delivery and clients' health-seeking behaviour. The findings show the need for a well-functioning health system with adequate and trained staff, a reduced staff workload, proper case recording, an improved patient follow-up system, better support for staff, the empowerment of PMTCT clients, strong leadership, and coordination and collaboration between partners.

Follow-up survey of women who have undergone a prevention of mother-to-child transmission program in a resource-poor setting in South Africa

The aim of this study was to investigate the implementation of a prevention of mother-to-child transmission (PMTCT) program and to evaluate the uptake and adherence to single-dose nevirapine in a cohort sample that had undergone PMTCT in five public clinics in a resource-poor setting, Quakeni Local Service Area, O.R. Tambo District in the Eastern Cape, South Africa. Results indicated that 116 women (15.3% of the sample) were infected with HIV, 642 (84.7%) were uninfected, and 552 (42.1%) had an unknown HIV status. Almost all of the women had received information about HIV and HIV testing prenatally, but 552 (42%) had not been tested for HIV, and their HIV status was unknown. Only 66 (57%) of the HIV-infected pregnant women had been provided with nevirapine. It is recommended that the quality of HIV counseling be improved and the program of maternal self-medication with nevirapine tablets at onset of labor and maternal provision of nevirapine syrup to newborns be encouraged.