Missed Prevention of Mother-to-Child Transmission of HIV (PMTCT) visits have contributed to the delayed achievement of elimination of mother-to-child transmission of HIV. Missed visits promote attrition from prevention of mother-to-child transmission of HIV program and antiretroviral drug resistance. The purpose of the study was to determine the prevalence of missed PMTCT visits and its associated predictors. A descriptive cross sectional survey was carried out at a District Hospital in Goromonzi, Zimbabwe. Fifty-three women completed closed-ended questionnaires pertaining to PMTCT visits and exposure to PMTCT activities. A total of 24.5% missed at least one scheduled PMTCT visit. Statistically significant predictors of not missing a PMTCT visit were satisfaction with family support (β = −0.73, p = 0.029) and level of satisfaction with PMTCT services (β = −0.00076; p = 0.04). The number of days by which scheduled visits were missed were inversely correlated with visit number (β = −2.99, p = 0.04). Enhanced family support and quality improvement to improve patient satisfaction may reduce missed visits. Availing women with a more active role in PMTCT may also reduce the prevalence of missed visits.
Prevention of Mother-to-Child Transmission of HIV (PMTCT) is a key strategy in the global AIDS response towards elimination of HIV and AIDS by 2030 [
Countries are aiming to achieve the 90-90-90 targets by 2020. According to the targets, by the year 2020, 90% of people with HIV should know their status and 90% of people diagnosed with HIV infection should be on lifelong antiretroviral therapy. The last 90 in the 90-90-90 strategy aims to have 90% on ART having viral suppression [
Many innovative strategies have been used to improve retention in PMTCT, hence reduce the frequency of missed visits. The retention interventions can be health centre based or community-based. In a 2016 systematic review of interventions to improve retention, identified strategies to improve retention in PMTCT included task-shifting to enable nurses to prescribe antiretroviral drugs, integrating PMTCT services in antenatal clinics (ANC), quality improvement at health centres, CD4 testing at health centres, facility-based peer support, encouraging male partner support and using cell phone reminders [
Despite all these interventions being implemented in most settings, retention remains poor [
The pilot study was conducted through a descriptive survey method in October 2016. Two questionnaires were administered. Both questionnaires had closed-ended items. They were administered to randomly selected women enrolled in PMTCT at Makumbe District Hospital, Zimbabwe. The study site was purposively selected for having a diverse catchment area, which included rural and urban population. Randomization was achieved through coin flipping. Only women enrolled in PMTCT Option B plus at the site and could understand either English or the vernacular Shona language were approached. Women who were enrolled in the Option B program or who visited the PMTCT centre for emergency supply of antiretroviral drugs [ARVs] were excluded from the study. A total of 53 women were selected to participate in the study. The sample size was based on the central limit theorem [
The study observed ethical principles according to the Nuremberg code. The investigator had a valid competence in ICH-GCP (International Conference on Harmonization―Good Clinical Practice). Approval to conduct the study was granted by both the J REC (Joint Research Ethics Committee for University of Zimbabwe College of Health Sciences and Parirenyatwa Group Hospitals) and The Medical research Council of Zimbabwe (MRCZ). Data were analyzed for descriptive statistics and both multiple linear and multiple logistic regression using STATA software.
Fifty-three women in PMTCT participated in the study. The age of participants showed a multimodal beta distribution with modal ages of 29, 32 and 33 years (γ = −0.003; SD = 6.7). Forty-one (77.4%) participants had attained secondary school education; one [1.9%] had a tertiary education qualification. Forty-six (86.8%) participants were rural dwellers. Thirty (56.6%) participants were unemployed. It was not surprising that 46 (86.8%) had a monthly income not exceeding US$250. On the other hand, 48 (90.6%) were Christians while 2 [3.8%] were affiliated to the traditional religion. Thirty participants (56.6%, 95% CI = 0.4; 0.7) were pregnant and 43.4% (95% CI = 0.3; 0.6) were breastfeeding. Both the duration of pregnancy and duration of breastfeeding were negatively skewed. The median duration of pregnancy was 6 months (IQR = 2 months). The median duration of breastfeeding was 5 months (IQR = 9 months). The male condom, used by 19 (35.8%) and The Progesterone only pill (POP), used by 13 (24.5%) participants and Depo Provera®, used by 10 (18.8%) participants, were the commonly used methods of family planning by the participants. All participants had disclosed their HIV positive status to their husbands or partners. The participants’ demographic characteristics are summarized in
Forty-seven (88.7%) participants the health centre as their usual source of health care and 30 (56.6%) had visited the health centre at least once in the previous year. Only seven (13.2%) spent more than 3 hours coming to the health centre. The participants’ mean distance from the Hospital was 8.1km (SD = 5.4 km) and travelled to the Hospital in an average of 57 minutes (SD = 38.3 minutes). Thirteen [(4.5%) participants had missed a scheduled visit. Another 13 (24.5%) were members of an HIV-related support group. Since commencing the recent PMTCT program, the participants had a mean of 7 (SD = 5.4) PMTCT visits. On the other hand, the participants had a median of 12 months (IQR = 19 months, skewedness = 2.7). Lastly, the participants had missed the current scheduled visit by up to 62 days. Those who had come earlier than the scheduled review date did so by up to 23 days before the scheduled PMTCT visit. Those who reported having come to the PMTCT centre were 22 (41.5%). The mean participants’ CD4 count was 463 cells/µL (SD = 322.6 cells/µL). Participants CD4 counts ranged between 6 and 1360 cells/µL. Data for the current participant visit is summarized in
According to
The instrument for participant satisfaction with the PMTCT programme at the hospital yielded a Cronbach’s alpha of 0.92. The mean satisfaction score was bimodal with a median of 28 (IQR = 8). The 33.3 percentile was 25 and the 66.7 percentile was at a total score of 30. Thus, scores below 25 implied poor satisfaction and a score of 30 implied complete satisfaction. Values in between reflected
Variable | Frequency | Percentage |
---|---|---|
Level of education | ||
Primary | 11 | 20.8 |
Secondary | 41 | 77.4 |
Tertiary | 1 | 1.9 |
Place of residence | ||
Urban | 7 | 13.2 |
Rural | 46 | 86.8 |
Employment | ||
Formally employed | 8 | 15.1 |
Self-employed | 15 | 28.3 |
Unemployed | 30 | 56.6 |
Monthly income | ||
$0 - $250 | 46 | 86.8 |
$251 - $600 | 6 | 11.3 |
Above $600 | 1 | 1.9 |
Religion | ||
Christianity | 48 | 90.6 |
Traditionalist | 2 | 3.8 |
Moslem | 3 | 5.7 |
Duration on ART | ||
Less than 3 months | 7 | 13.2 |
3 - 12 months | 10 | 18.9 |
1 to 3 years | 20 | 37.7 |
More than 3 years | 16 | 30.2 |
Stage in PMTCT | ||
Pregnant | 30 | 56.6 |
Breastfeeding | 23 | 43.4 |
Family Planning method | ||
None | 2 | 3.8 |
Male condom | 19 | 35.8 |
Female condom | 3 | 5.7 |
Jadelle® | 3 | 5.7 |
Depo Provera® | 10 | 18.8 |
POP | 13 | 24.5 |
COC | 3 | 5.7 |
Disclosed to husband or partner | ||
Yes | 53 | 100.0 |
Total | 53 | 100 |
Variable | Frequency | Percentage |
---|---|---|
Is this your usual source of health care | ||
No | 6 | 11.3 |
Yes | 47 | 88.7 |
Travel time to hospital | ||
Less than 1 hour | 27 | 50.9 |
1 - 3 hours | 19 | 35.8 |
More than 3 hours | 7 | 13.2 |
Duration of exposure to Hospital | ||
Less than 6 months | 6 | 11.3 |
6 - 12 months | 11 | 20.8 |
1 - 3 years | 16 | 30.2 |
More than 3 years | 20 | 37.7 |
Hospital visits in past 2 months | ||
None | 28 | 52.8 |
One or two | 9 | 17.0 |
More than 2 | 16 | 30.2 |
Hospital visits in the past year | ||
None | 23 | 43.4 |
One or two | 13 | 24.5 |
More than 2 | 17 | 32.1 |
Hospital being planned centre of delivery | ||
Yes | 39 | 73.6 |
No | 14 | 26.4 |
Type of visit | ||
Scheduled | 42 | 79.2 |
Unscheduled | 11 | 20.8 |
Missed a scheduled visit | ||
Yes | 13 | 24.5 |
No | 33 | 62.3 |
Transport cost per visit | ||
No direct monetary cost | 8 | 15.9 |
Less than $10 | 42 | 79.2 |
$11 - $20 | 3 | 5.7 |
Membership to a support group | ||
Yes | 13 | 24.5 |
No | 36 | 66.0 |
Do not know | 4 | 7.5 |
Coming for PMTCT with partner | ||
Yes | 22 | 41.5 |
No | 31 | 58.5 |
Variable | Frequency | Percentage |
---|---|---|
Receiving peer support | ||
Yes | 14 | 26.4 |
No | 39 | 73.6 |
Receiving community health worker support | ||
Yes | 18 | 34.0 |
No | 35 | 66.0 |
Having had a cell phone reminder for PMTCT services | ||
Yes | 15 | 28.3 |
No | 38 | 71.7 |
Cash motivation to come for visits | ||
Yes | 5 | 9.4 |
No | 48 | 90.6 |
Referral for: | ||
Blood tests | 2 | 3.8 |
X-ray | 8 | 15.1 |
Antiretroviral drugs | 0 | 0.0 |
Cotrimoxazole | 4 | 7.5 |
Hospital admission | 4 | 7.5 |
Outpatient treatment | 1 | 1.9 |
Sex of health care worker | ||
Male | 1 | 1.9 |
Female | 52 | 98.1 |
Know health worker by name | ||
Yes | 26 | 49.1 |
No | 27 | 50.9 |
Services paid for | ||
Booking | 46 | 86.8 |
Consultation | 1 | 1.9 |
Supplies or equipment | 5 | 9.4 |
Medication | 2 | 3.8 |
Laboratory tests | 3 | 5.7 |
Present health | ||
Excellent | 26 | 49.1 |
Good | 16 | 30.2 |
Average | 10 | 18.9 |
Poor | 1 | 1.9 |
Progress in PMTCT | ||
Improved | 42 | 79.2 |
Still the same | 8 | 15.1 |
Worsened | 3 | 5.7 |
Satisfied with family support in PMTCT | 48 | 90.6 |
Satisfied community support in PMTCT | 37 | 69.8 |
Current HIV status of child | ||
Positive | 4 | 7.5 |
Negative | 30 | 56.6 |
Unknown | 19 | 35.9 |
optimal satisfaction. Nineteen (35.8%) had complete satisfaction with PMTCT services at the hospital,
Multiple linear regression yielded two statistically significant predictors of missing a visit, namely; satisfaction with family support (β = −0.73, p = 0.029) and level of satisfaction (β = −0.00076; p = 0.04). On the other hand, there was an inverse correlation between the current visit number and the number of missed days (β = −2.99, p = 0.04). Other predictors of missed PMTCT visits such as income, transport cost to health facility, CD4 count, peer support and community health worker support were not statistically significant.
Findings from this study showed that 24.5% of the women missed a scheduled visit. Satisfaction with the PMTCT programme at the health centre and family support were associated with not missing a PMTCT visit. Not surprisingly, participants who had just been commenced on PMTCT, that is, with few PMTCT visits were more likely to miss a scheduled visit by more days.
In this study 24.5% participants missed the scheduled PMTCT visit. This was a lower figure than in a national survey whereby 43% were lost to follow up by the time of the third drug pick up [
motivation, and 71.7% had no cell phone reminders. This may imply that coming for scheduled PMTCT visits is much of individual effort. Surprisingly, a study in South Africa found that by six weeks after delivery, 24% women had missed a PMTCT visit [
In this study, 35.8% participants had complete satisfaction with PMTCT services. This was a low figure compared to a study in Dar es Salaam where 61% had very good satisfaction. In the Dar es Salaam study, predictors of dissatisfaction included long waiting times, poor comprehension of patient needs and poor interpersonal skills of health workers [
Statistically significant predictors for not missing visits were participants’ satisfaction with family support and satisfaction with PMTCT services at the hospital. In this study, 90.6% were satisfied with family support and 69.8% were satisfied with community support. The findings contrast with a Haitian study whereby socio-demographics were not predictors of retention in care [
However, the statistical power in the current study may have been compromised by the small sample size. The study was also done in a single month, which might have produced a selection bias.
Family support and satisfaction with the handling of the PMTCT program may reduce the likelihood of missed PMTCT visits. Women tend to have more missed days in the later days of the PMTCT cascade. A more comprehensive PMTCT site assessment is required. The site assessment may include site retention strategies and the presence of a sustainable PMTCT model capable of retaining women in PMTCT. Hence, reducing the frequency of missed visits may facilitate understanding of health care and community predictors of missed visits. Lastly, a qualitative study to explore the reasons why women miss scheduled PMTCT later after enrollment into the PMTCT programme, may be done to explain patient fatigue along the PMTCT cascade.
The authors would like to acknowledge the Provincial Medical Director, Mashonaland East Province and the District Medical Officer, Goromonzi for their support in data collection. This work is supported by the Norwegian Agency for Capacity Development (NORHED).
Ndaimani, A., Chitsike, I., Haruzivishe, C. and Stray-Pedersen, B. (2017) Missed Prevention of Mother-to-Child Transmission of HIV (PMTCT) Visits and Associated Programmatic Predictors: A Pilot Study. Advances in Infectious Diseases, 7, 107-117. https://doi.org/10.4236/aid.2017.74011