Access to Prevention of Mother to Child Transmission of HIV-1 Services in Kenya: Social and Structural Determinants
Kohler, Pamela Kay
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Introduction: Interventions to prevent mother-to-child transmission (PMTCT) of HIV are remarkably efficacious. However, although PMTCT coverage has increased, there remain gaps between availability of PMTCT services and uptake of PMTCT interventions. It is critical to determine modifiable individual, social and programmatic barriers to delivery of PMTCT. Methods: To assess rates and correlates of PMTCT uptake, a cross-sectional community-based survey among women of child-bearing age was performed in the Health Demographic Surveillance System (HDSS) in Nyanza Province, Kenya. Concurrently, a cross-sectional survey assessing service capacity for PMTCT was performed at 40 maternal health facilities in the region. Results: Antenatal care (ANC) attendance was associated with education (OR 6.7; 95%CI 2.0-22.9) and fewer prior pregnancies (OR 0.8; 95%CI 0.7-0.9). Most (87%) women attending ANC were HIV tested. Maternal HIV testing was associated with better socioeconomic status, partner HIV testing and absence of shame if associated with someone with HIV. Among 216 HIV-seropositive women, 82% took PMTCT antiretrovirals (ARVs). Maternal ARV use was associated with HIV-tested partner (OR 2.7; 95%CI 1.3-5.9), number of ANC visits (OR 1.7; 95%CI1.2-2.4) and shame (OR 0.5; 95% CI 0.3-0.9). Receipt of ARVs during labor was associated with facility delivery (p<0.03). HIV-positive women were more likely to deliver at a health facility than HIV-negative women (p<0.001) and traveled longer to delivery care. Women who bypassed nearby facilities traveled to higher tier facilities offering more comprehensive services. Among 40 ANC facilities surveyed, 95% offered HIV testing. Approximately half of facilities (55%) reported offering HIV testing to families of women tested. Thirty-three facilities (83%) reported offering PMTCT services; 60% had CD4 count measurement capability and infant PCR testing access. Median time to CD4 result was one week (IQR 2-14 days) and time to PCR was 3 weeks (IQR 14 to 30 days). Conclusions: Interventions that may improve uptake of PMTCT include facilitation of partner involvement, promotion of facility delivery, and HIV-specific educational interventions. Opportunities exist in maternal counseling or peer support, as well as media campaigns for stigma reduction. At the health-services level, family testing and implementation of point-of-care services at lower-tier facilities may further improve uptake of PMTCT services.
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