Among women who attended at least one ANC visit, almost all were either tested for HIV in pregnancy if their status was negative or unknown (95.7% of adolescents vs. 91.6% of adults) or they already knew they were HIV positive before pregnancy (0.4% vs. 4.7%). There were no significant differences between adults and adolescents in coverage of HIV testing in pregnancy [OR 0.95 (95% CI: 0.19 to 4.71), P = 0.95].
ARV use for PMTCT was evaluated in all HIV-positive women attending at least one ANC visit, from the 2 surveys combined. A lower proportion of adolescent women were on ART for their own health before pregnancy than adult women (4.8% vs. 43.1%, respectively). Of the women who were not on ART pre-pregnancy (n = 288), 85.8% of adults but only 65.0% of adolescents took ARVs for PMTCT (P = 0.01 for the comparison). Adolescents had one-third odds of using maternal ARVs for PMTCT compared with adults [OR 0.31 (95% CI: 0.12 to 0.80), P = 0.02]. In a model adjusted for marital status, HIV status disclosure and attendance of at least 4 ANC visits, being an adolescent remained a significant predictor of lower maternal ARV use [aOR 0.32 (95% CI: 0.11 to 0.92)] (see Table 2 and Supplemental Digital Content, Table S1, http://links.lww.com/QAI/A918). The most common reasons women gave for not using ARVs for PMTCT were not receiving them from the health care provider (52.6% of adults who had not received ARVs and 57.1% of adolescents who had not received ARVs), and being diagnosed with HIV late in pregnancy or after delivery (18.4% of adults and 42.9% of adolescents).
Among HIV-positive women who attended at least one ANC visit (Fig. 1), 97.7% of infants born to adult women received ARVs for PMTCT compared with 85.7% of infants born to adolescent women (P = 0.005). Being an adolescent was negatively associated with use of infant ARVs [OR 0.15 (95% CI: 0.03 to 0.65), P = 0.01]. In a model adjusted for timing of HIV diagnosis, HIV status disclosure, and facility delivery, a trend persisted for the association between being an adolescent and infant ARV use [aOR 0.21 (95% CI: 0.03 to 1.52), P = 0.12] (see Table 2 and Supplemental Digital Content, Table S1, http://links.lww.com/QAI/A918). Notably, infant ARV uptake in both adults and adolescents was higher than maternal ARV uptake. The most common reasons that women gave for their infants not using ARVs were not receiving them from their health care provider (18.2% of adults, 66.6% of adolescents), being diagnosed with HIV after delivery (27.3% of adults, 33.3% of adolescents) and not disclosing their HIV status (27.3% of adults, not cited by adolescents).
As an additional assessment of possible mediation or modification of the effect of being an adolescent on engagement in the PMTCT cascade by sociodemographic characteristics of adolescent women, analyses were stratified by characteristics that differed between adolescents and adults and showed a significant association with our outcome of interest. Figure 2 summarizes the association between being an adolescent and attendance of 4 or more ANC visits, stratified by employment, gravidity, pregnancy intention, and HIV status. In most strata, the association between being an adolescent and incomplete ANC attendance persisted, although CIs were large in analyses of employed women, women who were not in their first pregnancy, and HIV-positive women. These were the smallest strata, with fewer than 20 observations in the adolescent group. Given the small number of HIV-positive adolescents in our study (n = 21), we did not have sufficient power to conduct stratified analyses of maternal or infant ARV uptake.
Correlates of ANC Attendance Within Adolescents
To explore the adolescent-specific correlates of engagement in the PMTCT cascade, characteristics of adolescents who were engaged in the PMTCT cascade were compared with those who were not. Given the small sample size of HIV-positive adolescents, ANC attendance among adolescents of all HIV statuses was evaluated. Table 3 summarizes correlates of adolescent attendance of 4 or more ANC visits. Although 74.3% of adolescents who attended fewer than 4 ANC visits had disclosed their HIV status to their partner, 82.8% of adolescents who attended at least 4 ANC visits had disclosed. In logistic regression, disclosure had a borderline association with attendance of at least 4 ANC visits [OR 1.67 (95% CI: 0.98 to 2.84), P = 0.06]. Similarly, although 63.3% of adolescents who attended fewer than 4 ANC visits were married, 71.8% of adolescents who attended at least 4 ANC visits were married, and this also had a borderline association by logistic regression [OR 1.66 (95% CI: 0.91 to 3.04), P = 0.10].
Pregnant adolescent women represent a vulnerable group with respect to HIV incidence, HIV testing coverage, and HIV-related mortality.4,21 Integrated PMTCT services in routine antenatal care present a crucial opportunity to identify young HIV-infected pregnant women and link them to HIV care and PMTCT services.
In this study, we evaluated engagement of adolescent and adult women in the PMTCT cascade, using data from a national evaluation of the Kenyan PMTCT program. We found that 12.8% of women of any HIV status and 4.2% of HIV-positive women were 19 years old or younger, and these adolescent women showed lower engagement at 3 steps in the PMTCT cascade: attendance of 4 or more ANC visits by women of any HIV status, use of maternal ARVs by HIV-positive women, and use of infant ARVs by HIV-positive women. We found that attendance of at least 4 ANC visits was significantly associated with maternal and infant ARV uptake (Supplemental Digital Content, Table S1, http://links.lww.com/QAI/A918), highlighting the interrelatedness of the steps in the PMTCT cascade.
Our findings are consistent with previous studies reporting lower PMTCT coverage in adolescent mothers in other African contexts.15–17,22 Furthermore, our analysis of individual steps in the PMTCT cascade helps define the points at which adolescents are underserved. We found no significant difference between adults and adolescents in attendance of at least one ANC visit, gestational age at first ANC, or HIV testing in pregnancy. This suggests that initial presentation at ANC and HIV testing is similar across age groups, but adolescents show lower retention in ANC irrespective of HIV status, and HIV-positive adolescents show lower uptake of ARVs for PMTCT. Echoing the calls for improved HIV testing and treatment of adolescents,23 these findings argue that adolescents face unique challenges in uptake of PMTCT services, specifically in returning for the recommended number of ANC visits and using ARVs for PMTCT.
Our findings suggest that maternal age alone, a characteristic routinely ascertained in clinical care, can act as an indicator of risk and need for targeted support. Furthermore, we observed that >70% of HIV-positive adolescents were diagnosed during pregnancy, highlighting the importance of antenatal care as an opportunity to identify HIV-positive women in this group and link them to prevention and care.
Development of interventions that improve adolescent engagement in the PMTCT cascade requires an understanding of the barriers experienced by adolescent pregnant women. Our analysis offers some insight into factors associated with adolescent engagement. In multivariable and stratified analyses, we found that being an adolescent remained significantly associated with incomplete ANC attendance independent of employment, household crowding, pregnancy intention, gravidity and HIV status. This suggests that lower attendance by adolescents is not explained by differences in the other maternal predictors of attendance we identified. Similarly, maternal ARV use was independently associated with being an adolescent in multivariable analysis adjusted for marital status and HIV status disclosure, suggesting lower uptake of ARVs by adolescents was not explained by these characteristics. The association of being an adolescent with infant ARV showed borderline statistical significance in multivariable analysis, suggesting it may partly be explained by differences in HIV status disclosure or facility delivery between the groups (although this may also be due to limited statistical power).
A number of factors beyond the demographic and obstetric characteristics that we measured may be responsible for our observation of lower adolescent engagement in the PMTCT cascade. When asked why they had not received maternal or infant ARVs, both adult and adolescent women reported not being prescribed ARVs by their provider and being diagnosed with HIV late, suggesting health system factors may be at play. Our sample size was too small for a formal comparison of reasons between age groups. Previous studies examining PMTCT uptake in women of all ages have suggested both individual level and systemic facilitators and barriers (reviewed in Refs. 22,24,25). Facilitators include knowledge of HIV and PMTCT, skills to manage practical demands of taking medication and access to social support; barriers include transport to clinic, stigma, and negative interactions with health care workers. Few studies have investigated adolescent-specific barriers to ANC and PMTCT uptake; those that have report negative experiences with clinic staff26 and stigma related to both HIV status and adolescent pregnancy.27 Several of the barriers experienced by all women (transport, lack of HIV knowledge, lack of skills managing medication, and lack of social support) are likely heightened in younger women due to their psychological development, limited experience, and diminished power and agency. Interestingly, although we observed a disparity between adults and adolescents in uptake of both maternal and infant ARVs, levels of infant ARV use were overall higher than maternal ARV use, suggesting that barriers to maternal ARV use may be especially challenging.
Our analysis of the correlates of ANC attendance within adolescent women provides support for the role of social support in enabling PMTCT uptake. We observed a trend for adolescents who had disclosed their HIV status to their partner (whether positive or negative) and married adolescents being more likely to attend 4 or more ANC visits. Our statistical power was limited for this analysis, and our sample size too small to explore correlates of ARV use in HIV-positive adolescent women. However, these findings suggest that supportive partnerships in which women feel comfortable disclosing their HIV status act as an enabler to ANC attendance in adolescents. Of note, in analysis of the overall cohort, marital status was not significantly associated with ANC attendance, pointing to partner support as being especially important in adolescent women. Interventions that supplement adolescents' support structures, such as peer mentoring28 or mHealth29 approaches, may be promising for this group. Although not evaluated in our study, it is possible that as previously reported,26 negative interactions with clinic staff contributed to adolescents' lower PMTCT uptake in our study. Addressing this barrier may be an important step in improving adolescent antenatal care. Strategies proposed to achieve this include training staff to interact sensitively with adolescent patients, allowing more time for appointments with adolescents, and consulting adolescents in the design of youth-friendly services.30,31
Our findings must be interpreted in light of the study's limitations. Although this study was large and sampled 7 of 8 provinces in Kenya, the study was not designed for comparison of adult and adolescent mothers, so statistical power was limited for some of our analyses, in particular those restricted to HIV-positive women. Second, the data presented here are derived from self-reported responses to survey questions. However, women's responses were verified in their MCH booklet if available, and analyses restricted to verified data showed similar results. More than 75% of women's reported ANC attendance and maternal ARV use, but only 50% of reported infant ARV use, could be confirmed in their booklet. The findings related to infant ARV use should therefore be interpreted with some caution. Third, we collected data only on those women who presented for their infants' vaccination visits, thus excluding women who fell out of the system completely. These women are likely younger and have lower rates of ANC attendance,32 so their inclusion might further strengthen the association reported here.
In conclusion, this study highlights the need for improved engagement of adolescent pregnant women in antenatal care and the PMTCT cascade, and calls for more detailed studies on challenges faced by these women to inform interventions that help overcome them.
The authors thank the women who participated in the study and the study staff.
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PMTCT; cascade; adolescent; antiretroviral; ANC
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