Experiences With Antenatal Care and HIV Testing
Nonadherent women made fewer ANC visits (2.5 vs. 3.1, P < 0.001) and were more likely to present at later gestational ages (6.0 vs. 5.0 months, P = 0.05) than adherent women (Table 2). Although nonadherent women were marginally less likely to be offered HIV testing at their first ANC visit (88% vs. 95%), most women (97%) in both groups were encouraged to return for additional ANC. About 10% of both groups reported feeling pressured to get tested by health facility staff. Disclosure rates to partners were high in both groups but tended to be lower among nonadherent women (79% vs. 88%, P = 0.07). Disclosure rates to family, friends, or others were significantly lower (62% vs. 82%, P < 0.001) among women who did not adhere to the SD-NVP protocol. Only 39% of partners of nonadherent women were tested during the index pregnancy compared with 54% of adherent women. Nonadherent women more often reported being unaware of their partner's HIV status (47% vs. 34%) and having an HIV-uninfected partner (25% vs. 17%) than adherent women (P = 0.004). The majority of all women (>87%) were well aware that HIV could be transmitted from mother-to-child during labor, delivery, and breastfeeding regardless of their adherence status. Most women (>95%) reported that a health worker discussed the risks of mother-to-child-transmission when they received their HIV test results and/or at another ANC visit. Nonadherent women, however, were less likely to report that they trusted the ANC staff “very much” compared with adherent women (84% vs. 93%, P = 0.01).
Adherence to the ARV Prophylaxis and Place of Delivery
With regard to the type of nonadherence to PMTCT prophylaxis, about half (47%) of nonadherent women reported that they had ingested SD-NVP but that their infants had not (Fig. 1). Another large group (42%), however, reported that neither they nor their newborns ingested it. Just more than 5% of cases women noted that only their child had taken it. A similar proportion indicated that either they or their child had taken it but not at the recommended time or that child uptake was unknown.
Although all adherent women received SD-NVP from a health worker either during their pregnancy (92%) or at delivery (8%), just 60% of nonadherent women reported receiving it before the expected delivery and only an additional 1% at delivery (Table 3). A number of nonadherent women did not return to ANC and/or reportedly delivered before they were able to obtain the ARV prophylaxis. Even among the nonadherent women who delivered in a health facility, however, only 39% received it, with a great variability per site (0%-100%). Most women (94%) who received SD-NVP during pregnancy or delivery, whether they adhered or not to the PMTCT protocol, indicated that the health worker's explanation regarding drug ingestion was clear. A majority (>75%) discussed whether or not to take it with their partners. Discussion about PMTCT prophylaxis with family, friends, or others was less common among nonadherent women (53% vs.71% among adherent women, P = 0.01). About two thirds (66%) of women reported waiting for their husband's permission before making a decision regarding ARV prophylaxis uptake, and most women noted that their partners were supportive (∼85%) of their taking it. However, a larger proportion of nonadherent women reported that their partners were not supportive (9% vs. 1% among adherent women, P = 0.053).
Although almost all (>99%) adherent and nonadherent women were advised to deliver in a health facility, far fewer nonadherent than adherent women did so (28% vs. 86%, P < 0.001). Ultimately, all adherent women (per definition) ingested SD-NVP at the recommended time, and 80% of nonadherent women who received SD-NVP did so, representing 49% of all nonadherent women. Nonadherent women who received the ARV prophylaxis but did not take it said this was because they forgot (30%) or were afraid (30%), their labor had progressed too quickly (20%), or their husband or someone else was present (and presumably was unaware of their HIV status) (20%). Among women who ingested SD-NVP, the majority, but significantly fewer nonadherent than adherent women, reported taking it at the onset of labor (58% vs. 70%, P = 0.04). Women who ingested the drug at another point before, during, or after their delivery explained that this was because they had been instructed to do so by a health worker (40%), their labor occurred too quickly or they had not realized they were in labor (25%), they had not received specific instructions about when to take the ARV prophylaxis (17%), or because they had simply forgotten to take it then (14%).
Only 7% of infants born to nonadherent women ingested SD-NVP. Among the nonadherent women who delivered outside a heath facility, only 15% said that they or a family member brought the newborn to the health facility for SD-NVP ingestion, and in most of these cases (67%), this occurred beyond the recommended period for infant ingestion. As reasons for the child not being brought to health facility, nonadherent women most often indicated that they were not aware the child was supposed to come to the health facility (34%), were either ill, too weak, or did not have any assistance to bring the child (30%), or did not think the child could get HIV (27%). Only 15% of women mentioned that this was because the health facility was too far from their home.
In multivariate analysis, socioeconomic factors seemed to have little effect on women not receiving SD-NVP during pregnancy (model 1) or not delivering in a health facility (model 2) but exerted a stronger influence on nonadherence to the ARV prophylaxis protocol (Table 4). Unmarried women, women with no or little education, were significantly more likely to report that they or their child did not ingest SD-NVP at all or at the recommended time (model 3). Low education level was similarly associated with maternal nonadherence (model 4). Women making 2 or less ANC visits during pregnancy (as opposed to making 3 or more visits) were more likely to not receive SD-NVP during pregnancy, not deliver in a health facility, and adhere as well as their child to ARV prophylaxis (models 1-4). Women who were not offered HIV testing at first ANC visit were significantly more likely to not receive SD-NVP before delivery and to report that they and/or their newborn had not adhered to the PMTCT protocol or that they alone had not adhered (models 1, 3, and 4). Women whose partners were not tested during their pregnancy were less likely to receive SD-NVP and to ingest it (models 1 and 4). Not disclosing one's HIV status to someone other than a partner was associated with nonadherence in mother-infant pairs and in newborns alone (models 3 and 5). Reporting that one's partner was uninfected was marginally significantly associated with mother-infant pair adherence (model 3). Maternal nonadherence was also strongly predictive of newborn nonadherence.
In this study, we described experiences with PMTCT services among HIV-infected women in 12 public sector PMTCT sites in Rwanda and examined determinants of nonadherence to a SD-NVP ARV prophylaxis regimen. To our knowledge, this is the first study to explore determinants of adherence/nonadherence to PMTCT ARV prophylaxis in the context of a national program.
Our data suggest several bottlenecks in adherence to the ARV prophylaxis. First, over one third of nonadherent women never received the ARV prophylaxis from a health worker during their pregnancy despite all consulting for ANC at a site that provides PMTCT services. Multivariate analysis indicates that, among other factors, women who made 2 or less ANC visits were less likely to receive SD-NVP before their expected date of delivery. Second, despite universal recommendations to deliver in a health facility where ingestion of the ARV prophylaxis can be monitored, only 28% of nonadherent did so. Home birth was also shown as a factor associated with maternal nonadherence to SD-NVP among women participating in a PMTCT program in Zambia.22 Multivariate analysis suggests that socioeconomic factors had little effect on the ultimate place of delivery. Making 2 or fewer ANC visits, however, was strongly associated with not delivering in a health facility. Women who made few ANC visits had indeed fewer opportunities for health workers to reinforce the importance of delivering in a health facility. It might also reflect suboptimal utilization of all formal health care services among nonadherent women. Problematic interactions between providers and clients were previously cited as a barrier to adherence to the complete PMTCT protocol for some HIV-infected women in Côte d'Ivoire.28 In our study, although nonadherent women were somewhat less likely to report that they highly trusted ANC staff, this factor was not significantly associated with adherence after adjusting for confounders in logistic regression. Third, even among women who delivered in a health facility, ingestion of SD-NVP by mother and child was not fully achieved. It is important to understand the circumstances of such missed opportunities.10
Multivariate analysis suggests that in addition to health-seeking behaviors and service delivery factors, sociodemographic factors and social support also impacted whether mother-infant pairs ultimately ingested the ARV prophylaxis. Low levels of education, being unmarried, and not having disclosed one's test results to someone other than a partner were all independently associated with nonadherence among mother-infant pairs. Lower education level has previously been shown as a factor associated with nonacceptability to HIV testing,18 maternal nonparticipation in, or nonadherence to PMTCT.21,22-24 Schooling may impact on adherence in several ways including facilitating communication with health workers, increasing retention of information provided by health workers, and enhancing implementation of the recommendations regarding ingestion of the ARV prophylaxis. The effects of marital status and HIV disclosure to someone aside from one's partner on maternal-infant adherence highlight the importance of communication and social support. Discussion of HIV screening with partner, partner willingness to have HIV testing, or being effectively tested for HIV have been shown as predictors of acceptance of HIV testing by pregnant women16,20,23 and of compliance with SD-NVP uptake.22,23
Finally, only 15% of infants born at home were brought to a health facility for ingestion of SD-NVP. This is in line with data from rural Malawi showing that although 60% of women who delivered at home ingested SD-NVP, none of their babies were brought to the health facility to receive prophylaxis.25 To overcome this problem, a number of PMTCT programs are providing the SD-NVP infant's dose during pregnancy and most programs are trying to increase health facility delivery rates.
Our study presented some limitations. First, some of the HIV-infected women believed to be nonadherent to the national PMTCT protocol (according to available information in the site's registers) could not be located. It is possible that the sociodemographic profiles and health-seeking behaviors of these women differ from those of the women interviewed and thus that our sample of nonadherent women might not be representative of all such women. Unfortunately, we had no information regarding the women lost to follow-up. Second, as women interviewed had delivered their last pregnancy on average 5.5 months before data collection, we cannot rule out the possibility of recall bias, but if existing, this bias should be balanced among cases and controls.
In light of our findings, we suggest that when SD-NVP is used as PMTCT prophylaxis (alone or coupled with azidothymidine), it should be distributed to mothers at their first ANC visit, regardless of gestational age. Additional training to ensure that gestational dating is accurate and active tracing of women who do not come back to ANC might also help ensure that women do not deliver without receiving any PMTCT prophylaxis. ANC staff should make sure that messages, particularly those regarding timing of drug ingestion, are clear even to less educated women, and that counseling regarding disclosure during pregnancy is enhanced. Providing SD-NVP infant's dose during the pregnancy has also to be considered. Finally, it is important to ensure that pregnant women, including HIV-positive women, attend an adequate number of quality ANC visits and to increase accessibility to delivery in a health facility. To this end, overall improvement in access to and of quality of maternity care services are needed.
We thank Deborah Horowitz, Vianney Nizeyimana, Njero Micheu, and Joseph Ntaganira for assistance with interviewer training and data collection and Jonathan Gordin, Veronica Mugisha, and Cedric Yambabariye for inputs related to data management. We are grateful to Anne Buvé and Joris Menten for helpful comments regarding data analysis and interpretation. We also thank the Titulaires de Santé at the participating clinics and the 12 interviewers for their contributions.
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Keywords:© 2009 Lippincott Williams & Wilkins, Inc.
Africa; ARV; HIV; prevention of mother-to-child transmission; prophylaxis