Adherence of Option B+ prevention of mother-to-child transmission program and its associated factors among pregnant and lactating mothers in public health facilities of East Gojjam zone, Amhara region, Ethiopia, 2017

INTRODUCTION

Human immuno deficiency virus/acquired immune-deficiency syndrome (HIV/AIDS) is one of the most destructive epidemics that the world has ever witnessed. Globally, an estimated 36.7 million peoples living with HIV; 34.5 million adults, women age above 15 years were 17.8 million and 2.1 million children under the age of 15 years were living with HIV in the year 2016. Sub-Saharan Africa accounts for the greatest share.^1,2 The nationwide prevalence of HIV/AIDS infection among exposed infants through mother-to-child transmission (MTCT) was 17% in 2014. HIV prevalence in children under 5 years of age is increasing due to MTCT which accounts over 90% of the cases.^3,4 In 2012, over 900 000 women living with HIV globally received anti retro viral prophylaxis. In order to address children born free from HIV/AIDS; WHO has started to implement different strategies for the optimization of prevention of mother to child transmission (PMTCT) care and support. Option A, Option B, and Option B+.^5,6

The federal ministry of health of Ethiopia was adopted the Option B+ PMTCT program in August 2012 and started its implementation after wards.⁷ Although efforts to eliminate MTCT in Ethiopia is good; data from 2010 up to 2013 showed ARV treatment for HIV positive pregnant women was 55% and also MTCT of HIV after the breast feeding period in 2012 and 2013 were 32% and 25% respectively.⁸ The importance of studying on adherence of Option B+ PMTCT drugs and its associated factors help the country to contribute on the progress of the Option B+ PMTCT program in the assistance to eliminate MTCT in future pregnancies since the country’s main productive resource is the future young generation. The objective of this study was to assess adherence of Option B+ PMTCT drug and its associated factors among pregnant and lactating mothers in public health facilities of East Gojjam zone, Amhara region, Ethiopia, 2017.

METHODS

Institutional based cross sectional study design was conducted in public health institution in East Gojjam zone, Amhara region, Ethiopia from December 2016 to February 2017. Selected HIV positive pregnant and lactating mothers who visit ANC and PNC unit and on ART at least for 4 weeks in the selected public health facilities in the East Gojjam zone got PMTCT service during the study period were included but seriously sick individuals during interview were excluded.

To determine sample size, a single population proportion formula using the proportion of pregnant women who live in rural area which adhere to Option B+ PMTCT drug was 80%, confidence level of 95% and a 5% degree of precision then the final the sample size was 269.⁹

There are four hospitals and eighteen health centers in the zone. Using simple random sampling method one hospital and two health centers were selected which were providing Option B+ PMTCT service in east Gojjam zone during the study period. Debremarkos referral hospital, Bichena and Motta health centers were selected with random sampling method.

A structured questionnaire was used. One day training was given to data collectors by the researcher. The collected data were checked manually for its completeness and consistency daily by supervisor. After coded the data entered in to Epi data 3.1 software then was transferred to SPSS version 20 for analysis. Logistic regression model used for analysis by taking adherence of Option B+ PMTCT program as main outcome variable then odds ratio at p<0.05 with 95% confidence interval calculated to describe associations between dependent and independent variables. Variables with considering odds ratio if p<0.05 at CI: 95% from binary logistic regression analysis was entered to multivariate logistic regression model to identify significant factors. Then odds ratio of multiple logistic regression and p-value less than 0.05 at 95% CI used for statistical significance determination.

Ethical clearance obtained from Debre Markos University School of Medicine Institutional Research Ethics Review Committee. Permission letter obtained from East Gojjam zone health department and from respective health institutions. Informed consent obtained from each respondent. Privacy and confidentiality of the respondents was maintained through orientation which contributed for the quality of the study.

Operational definition

Good adherence

Using both self-report and pill count methods; mothers who did not miss any ARV drugs in the last four weeks prior to the interview and who answered correctly in 2 and more self-report questions from the four.¹⁰

Knowledgeable on HIV, MTCT and PMTCT Option B+ care

Mothers score ≥mean (0.90) from twenty three questions related with knowledge on HIV, MTCT and PMTCT Option B+ care categorized as knowledgeable on HIV, MTCT and PMTCT Option B+ care. The maximum score was 1 while the minimum score was 0.65.

Favourable attitude of mothers towards Option B+ PMTCT service

Mothers score ≥ mean (0.71) from five questions related with Attitude of mothers towards Option B+ PMTCT service. Minimum and maximum score were 0 and 1 respectively.

Good male partner involvement in Option B+ PMTCT program

Respondents score ≥mean (0.47) from seven questions related with male partner involvement in Option B+ PMTCT program categorized in to good male partner involvement in Option B+ PMTCT program. Minimum score 0 and maximum score 1.

RESULTS

Socio demographic and economic characteristics of the mothers

The total of 269 HIV positive pregnant and breast feeding women who visit ANC as well as PNC unit plus on ART at least for 4 weeks were included. The mean age of the study participant was 26.12+SD with minimum age of 19 and a maximum of 41. 153 (56.9%) of study participants were married, 197 (73.2%) were Orthodox Christians and 72 (26.8%) Muslim, 158 (58.7%) house wives and regarding educational status 176 (65.4%) cannot read and write. 189(70.3%) of respondent were resides in the urban area. About 114 (42.4%) of women took more than thirty minute to reach the health facility (Table 1).

Knowledge of mothers on HIV, MTCT, PMTCT Option B+ drug

All of the respondents knew about all ways of HIV transmission (unsafe sexual intercourse, contact with infected blood, MTCT and contaminated sharps). Regarding to MTCT majority of the respondents known as MTCT during delivery 242 (90%), during breast feeding 235 (87.4%) and during pregnancy 226 (84%) (Table 2).

Attitude of mothers towards Option B+

Regarding to attitude of mothers towards Option B+ PMTCT, 259 (96.5 %) of mothers agreed on taking PMTCT drugs benefits not only for the mother but also for the baby. 237 (88.1) of mother did not agree on the question of taking PMTCT drugs in every day is tiresome. In this study 129 (47.9%) of participants had favorable attitude (Table 3).

Male partner involvement

Regarding to male partner involvement 146 (54.3%) supports his wife financially to visit ANC/PNC to PMTCT and know the frequency of taking PMTCT drug. 140 (52%) reminds his wife about ANC/PNC appointment. In this study 191 (71%) mothers got good male partner support (Table 4).

ART treatment

127 (47.2%) were initiated lifelong ART before pregnancy, 106 (39.4%) were initiated lifelong ART (Option B+) during pregnancy, and 36 (13.4%) during breast feeding. All of the mothers reported as they got counseling about how to take Option B+ drugs as prescribed. 126 (46.8%) of respondents got counseling for more than three times and 110 (40.9%) took 20-29 minute duration of counseling per each session before drug initiation (Table 5).

Factors associated with adherence to Option B+ drugs

Age, mothers educational status, partner occupation, time to reach to health facility, HIV status at PMTCT enrolment, health status before treatment, drug side effects, knowledge, attitude and male partner involvement were found to be significant factors of adherence to Option B+ in binary logistic regression model. Variables with considering odds ratio if p<0.05 at CI: 95% from binary logistic regression analysis was entered to multivariate logistic regression model to identify significant factors. In multivariate regression analysis mothers’ educational status, partner occupation, time to reach to health facility and knowledge were significantly association with adherence to option B+ drugs. HIV+ pregnant and lactating mothers who could read and write were two times more likely have good adherence to Option B+ drug than mothers who could not read and write (AOR=2.03; 95%CI: 1.465, 8.918). HIV+ pregnant and lactating mothers whose partners were merchant was four times more likely to have good adherence for Option B+ drugs than mothers whose partners were daily laborers (AOR=4.73; 95%CI: 1.12, 19.87). HIV+ pregnant and lactating mothers who spend about 5-15 minutes to reach to health facility were 0.2 times less likely adherent than those who spend greater than 30 minutes (AOR=0.21; 95%CI: 0.05,0.824). Not knowledgeable mothers about HIV and Option B+ had 0.1 times less likely adherent than knowledgeable mothers (AOR=0.13; 95%CI: 0.03-0.44) (Table 7).

DISCUSSION

The level of adherence to Option B+ PMTCT drug in this study is low than that was reported from a study conducted in Bwaila Hospital, Malawi (91%) and study done in Nigerian among HIV positive pregnant mothers level of adherence (80.6%).^11,12 The possible explanation for this could be due to low partner involvement (62.9%) for option B+ program in this study. As well in this study a slightly higher number of respondents (65.4%) cannot read and write and almost half of the respondents were not knowledgeable on HIV, MTCT and PMTCT Option B+ drug (47%) so those had negatively associated with adherence to Option B+ PMTCT drug.

Institutional based study on level of adherence to Option B+ PMTCT program in Tigray region showed that the level of adherence to Option B+ PMTCT drugs was 87.1%.¹³ While in Yirgalem Hospital, south Ethiopia the adherence level for adult patient was 88.7%.¹⁴ This is higher than this study finding. The possible explanation for this low level of Adherence in this study could be due to study populations who had low knowledge (53.3%) about Option B+ drugs for PMTCT than others study populations. Furthermore, study participants’ support from their husband is low which affect their level of adherence for Option B+ PMTCT drug. As well there was a difference in study population in Yirgalem Hospital, adults but the study populations in this study were only pregnant and lactating mothers which might be the reason for the difference in level of adherence within two studies.

Institutional based study on level of adherence and associated factors to Option B+ PMTCT among pregnant and lactating mothers in selected government health facilities of South Wollo Zone in 2016 showed that level of adherence was 87.9%.¹⁰ The possible reason for low adherence level in this study could be due to most mothers educational statuses in this study were can’t write and read (65.4%).

Mothers who attend Option B+ PMTCT service in hospitals, HIV-positive pregnant and breast feeding mothers who were lived in the rural area and those HIV-positive pregnant and breastfeeding mothers who faced challenges (difficulties) on the same day HIV diagnosis and initiating lifelong ART were less likely to adhere for Option B+ PMTCT.¹⁴

Mothers educational status, partner’s occupation, time to reach the health facility and knowledge were factors associated with adherence to Option B+ PMTCT drug in this study. Unlike study done in Tigray region reported that, partner’s occupation and Knowledge about HIV and to Option B+ PMTCT was no significant association with adherence to Option B+ PMTCT drug.¹³ The reason might be due to slightly high number of merchant’s involvement (participation) in this study which may have differences in income level with study participants in other study. This discrepancy could be due to all mothers loves their children so; it is a precious agenda to have healthy newborn from HIV positive pregnant mothers who had not determined their happiness to get healthy neonates. Therefore, knowledgeable mothers about the ability of this Option B+ PMTCT drug had better adherence than not knowledgeable about HIV and Option B+ PMTCT drugs and have HIV free child.

CONCLUSION

Level of adherence to Option B+ PMTCT drug in public health facilities of East Gojjam Zone, Amhara region was low compared to the national goal. Promoting adherence to Option B+ drugs in all health facility is important to improve the long term maternal and child health. Mothers educational status, partner occupation, time required to reach to health facility and knowledge found to be significant association with adherence to option B+ drugs. Effort should be made to improve the knowledge about Option B+ PMTCT program to improve adherence to Option B+ PMTCT program.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

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