Uptake of prevention of mother-to-child transmission of human immunodeficiency virus interventions among infected mothers attending health facilities in Mombasa County, Kenya

INTRODUCTION

Mother-to-child transmission (MTCT) of HIV occurs when an HIV-positive mother transmits the virus to the baby. This takes place either antenatally, peripartum, or during breastfeeding. The virus infects 15-30% of infants born to HIV-positive mothers during pregnancy and childbirth, and 5-20% of them do so while nursing the baby.¹ In 2016, 36.7 million persons with HIV were found to be living in the globally. Among these, 2.1 million were children with a maximum age of 15.² One hundred and sixty thousand children between 0-14 contracted HIV in the same year.³ Sub-Saharan Africa has the highest rates of mother-to-child HIV transmission.

The global plan has 22 priority nations, 21 of which are in sub-Saharan Africa. Targets for universal coverage have not yet been met, with only 65% of HIV-positive pregnant women receiving ARV medication during PMTCT.⁴ Sub-Saharan Africa is home to up to 90% of all vertical HIV infections worldwide.³ Although the growth of PMTCT facilities has greatly benefited the Sub-Saharan region, penetration and usage remain low. The PMTCT interventions, including delivery in facilities and use of ARV, range from 20% to 57%.¹

Developing countries may not reach their goal of reducing the prevalence of HIV infections in infants by 90% if this condition persists.⁵ Globally, the Uptake of PMTCT interventions is estimated to be at 10 %, while in Africa, the Uptake is estimated to be between 10-15%. In Kenya, the Uptake could be better nationally at 8.5% and worse for Mombasa at 9.1%.⁶ Kenya is one of the 22 countries that account for 90% of all pregnant mothers with HIV worldwide.⁷ In Kenya, initiatives to reduce mother-to-child transmission (PMTCT) are seamlessly incorporated into Maternal and Child Health (MCH) services within healthcare institutions.⁸ Twenty-seven percent of Mombasa County women, as per the Kenya Demographic and Health Survey (KDHS) in 2022, are not aware that PMTCT for HIV is an option during pregnancy. Additionally, only 45.9 percent of newborns delivered to HIV-infected mothers receive infant prophylaxis, whereas 87 percent of maternal prophylaxis is administered.⁹ Both moms who are HIV-positive and mothers who are HIV-negative experience different pregnancy outcomes depending on their level of knowledge about maternal care and lifestyle choices.⁵ Effective prenatal care (ANC) depends on mothers' awareness and comprehension of these visits' advantages, which can encourage beneficial behavioral adjustments regarding health and the pursuit of reproductive health for both couples.¹⁰ Poor knowledge has been related to many factors, including a lack of formal education, poor infrastructure, and poverty, which can raise the likelihood of unfavourable pregnancy outcomes.¹¹

The usefulness of well-integrated PMTCT interventions, including patient counselling, in preventing HIV mother-to-child transmission was highlighted in research.¹² However, the survey also showed that 34.8% of women reported worries about the results of HIV screening during pregnancy because they were afraid of receiving a positive result. It has been demonstrated that PMTCT programs that offer counselling, education, and the development of social support networks can allay anxieties related to a positive HIV test result.³ Lack of knowledge of the disease reduces the use of PMTCT services in low-income countries.

An investigation into some of the factors contributing to the rising rate of HIV infection in children was carried out in Ethiopia. According to the researcher, incompetent healthcare providers affected the efficacy of PMTCT programs. Insufficient health facilities and the behaviors of health workers have been obstacles to using these resources.¹⁴ Low-quality maternity services, lack of drugs, and provider's attitude often affect the use of facilities.¹⁵

HIV-positive expectant women's attitudes toward healthcare providers and the availability of medical supplies and appliances determine whether to take up PMTCT.¹⁶ Specific considerations, such as length of stay in the hospital, are even more important than these factors. In the Ivory Coast, it was deduced that the length of stay to be served led to the low rate of people using PMTCT services, lack of follow-up, and stigma surrounding the PMTCT program.¹⁷ Research indicates that mothers are more adherent to PMTCT services, such as taking infant and maternal ART, when they deliver in health facilities, as opposed to those who do not. For pregnant HIV-positive women, professional delivery is essential due to the simultaneous risk of HIV transmission in the foetus and maternal death.¹⁸

METHODS

Study design, site and population

We conducted a cross-sectional study using exit interviews (post-ANC service) with pregnant women aged 15-45 from selected health facilities in Mombasa, County in Kenya between May 2021 to December 2021. Mombasa County has a population of 1,097,472. Among the healthcare workers, the county had 132 nurses, 52 doctors, and 93 clinical officers for every 100,000 people. The following categories apply to healthcare facilities available in the county: 58 public, 12 non-governmental organizations, 14 hospitals serving religions, and 237 private hospitals 19. Among Kenya's HIV infections, Mombasa has the greatest rate of mother-to-child transmission (9.1% vs. 8.5%). 19. Three health facilities in Mombasa County that offer PMTCT services were used for the study: coast general teaching & referral Hospital, the Port Reitz Sub County hospital, and the BOMU hospital. Women in Mombasa County who were HIV-positive made up the study's population.

Inclusion and exclusion criteria

Inclusion criteria were; HIV-positive mothers who attended a six-week postnatal clinic, mothers who were at least 18 years old, and mothers who accepted and gave consent for the study. Mothers who did not consent to participate in the study were excluded.

Sample size estimation

Sample size estimation was done using the formula by Fischer et al at a 95% confidence interval and prevalence of 50% because the exact proportion of Mombasa County youths who utilize reproductive health services is not well known.

Where n=the desired sample size, z=the value confidence level of 1.96 (95%), p=0.79 Proportion of paediatric disclosure (NASCOP, 2017), q=1-p and d=0.05 (the amount of discrepancy tolerated on q). Thus, the sample size was calculated as n= 267. The sample size was modified because the study's target population (690) was less than 10,000.

Where nf = the required sample size when the population is less than 10,000, N=the estimate of the target population size (690). Thus, nf=193. Considering the 10% non-response rate, the new sample size is 212.

Sampling procedure

The three top referral hospitals in the county Coast General Teaching and Referral Hospital, Port Reitz, and Bomu Hospital were chosen purposively. To sample individual respondents, proportionate sampling based on the target population was performed in each stratum.

A sampling frame was created, and a list of all postnatal mothers registered in the three hospitals for PMTCT was included. The subjects gave their informed consent after receiving a description of the study's mechanics.

Data collection techniques

A structured pre-tested questionnaire was applied to participants who consented to the study drawn from all the study sites. The questionnaire was administered either in English or Kiswahili depending on the preference of each respondent.

There was consistent use of a standardized interview translation protocol, training procedures, and use of appropriate language to minimize interpersonal variation in data quality. Completed questionnaires were checked for completeness.

Data management and analysis

Data entry was done in Epidata 3.1 data entry software. Using STATA version 14, quantitative data was analysed. Socio-demographic factors were described using descriptive statistics.

The association between the study variables was inferred using inferential statistics (t-test and ANOVA test). The dependent variable (Uptake) was tested using a chi-square test against the following independent variables. The predictive determinants of PMTCT uptake were identified using a multivariate logistic regression model, p value less than 0.05 was considered significant. The results of the data analysis were presented in tables, graphs, and charts

RESULTS

Socio-demographic characteristics of the participants

The mean age of the mothers (years) was 27.4±6.1. Most of the respondents 98 (47.3%) were married followed by single 56 (27.1%). Regarding employment status, 78 (37.7%) were housewives, 62 (30%) were self-employed and 40 (19.3) are in informal employment.

On matters religion, most 81 (39%) of them were Christians followed by 62 (30%) who were Muslims (Table 1).

Level of uptake of PMTCT interventions among postnatal HIV-positive mothers

Majority 176 (84.8%) of the respondents revealed that indeed their babies were exclusively breastfed while the rest 31 (15.2%) reported that they did not practice exclusive breast feeding.

Results showed that the majority 160 (77.3%) of the babies were given ARVs while the rest 47 (22.7%) were not given. Most of the respondent’s 144 (69.6%) revealed that ARVs were given during clinic follow-up and 63 (30.4%) were not given (Table 2).

Knowledge of who can be enrolled in PMTCT

Respondents were asked to indicate the kind of HIV mothers who can be enrolled in the PMTCT program. The (Figure 1) presents the number of times the respondents mentioned each option.

Most respondents (53.7%) knew all pregnant HIV-infected women, postnatal HIV-positive women, and their children should be enrolled in PMTCT, followed by all pregnant HIV-infected women (41.0%).

Knowledge of when the vertical transmission of HIV occurs

The (Figure 1) presents respondents' awareness of when vertical transmission of HIV could occur.

Most respondents reported that vertical transmission is likely to occur during the labour process and delivery (54.5%), followed by during breastfeeding (41.2%). At 1.9%, respondents opined that vertical transmission occurred during the antenatal period. Though the study's respondents demonstrated noticeably high levels of awareness of mother-to-child transmission (54.5% and 41.2%), the remaining percentages (2.3% and 1.9%) are still crucial because they may be the primary source of mother-to-child transmission in nursing children after six weeks of HIV-negative testing (Figure 2).

Knowledge of PMTCT methods among the respondents

In this study, among all of the respondents, 186 (89.9%) respondents had knowledge on ARVs for children. One-hundred and eighty-eight (90.8%) participants knew about early infant diagnosis of HIV while 173 (83.5%) had accurate knowledge of HIV counselling and testing. One hundred and sixty respondents (77.3%) knew Modified infant feeding practice and 176 (85%) were aware of the importance of delivering in a health facility. One hundred and sixty (77.3%) respondents were found to have correct knowledge of HIV-infected persons taking ARVs during and after pregnancy (Table 3).

Knowledge of the PMTCT intervention

The correlation between understanding of PMTCT techniques and adoption of PMTCT interventions is presented in (Table 4). Seventy-nine (77.5%) of the respondents who utilized PMTCT had correct knowledge of HIV counselling and testing which differed significantly when compared to 23 (22.5%) (χ² =8.99, df=1; p<0.05). A higher percentage of HIV infected individuals who utilized PMTCT were found to have correct knowledge of taking ARVs during and after pregnancy 136 (78.2%) compared to 38 (21.8%) who did not (χ²=14.15, df=1; p<0.05). Likewise, HIV infected women who utilized PMTCT interventions as compared to those who did not were found to have correct knowledge of delivering in health facility (132;81.5% vs. 30; 18.5%; p<0.05), modified infant feeding practice (146; 78.9%) vs. 39; 21.1%; p<0.05), early infant diagnosis of HIV (147; 79.9%; vs. 37; 20.1%; p<0.05) and ARVs for children (147; 79.9% vs. 37; 20.1%; p<0.05).

DISCUSSION

In this current study, we found that utilization of maternal and child MCH services was very high among HIV-positive participants including enrolment into care, taking ARVs, and delivering from a health facility. This is demonstrated by the high ANC attendance, positive HIV testing results at ANC, the fact that all deliveries occur in a medical institution, and the frequency of new-born follow-up visits. Other African studies have reported similar findings.²¹ Given the efficacy of Antiretroviral Therapy ART in HIV infection control, and especially where treatment adherence is good, high program uptake can translate into a significant reduction in the burden of HIV infections in the pediatric population. Most of the women interviewed opined that they followed the instructions very seriously to protect the young from the disease. During the follow-up study, 89.0% of the women were given ARVs during follow-up clinic, and their babies were also given. This demonstrates that the postnatal HIV-positive women in the chosen Mombasa hospitals favourably embraced the PMTCT interventions. This is inconsistent with a study conducted in Abidjan, Côte d'Ivoire, which discovered that poor adoption of PMTCT interventions in a prenatal clinic was caused by underlying mistrust in healthcare institutions and skepticism toward test results.²² Age positively correlates with the utilization rate of these treatments, according to a study by Merga, Woldemichael, and Dube 2016. Younger women are more likely to PMTCT services than older women. Additionally analyzed factors affecting the frequency of PMTCT uptake in Tanzania.²³ They asserted that the utilization in unmarried women is low, presumably due to a lack of support from male partners.

According to the study's findings, 54.5% of the respondents knew that mothers can transmit HIV to their unborn children and that all HIV-positive pregnant women, postpartum HIV-positive women, and their unborn children are required to participate in PMTCT. The current study finding was higher than the finding of studies done in Gahanna 25%, Tanzania 35.2%, South Africa 23.1%, and 30.1% in Uganda.²⁴ This finding is lower than the study conducted in a similar setting in Addis Ababa, Ethiopia 90.3%, Hawassa Referral Hospital, Ethiopia 90.1%, and Uganda 93%.^25-27 This variation of findings across various studies might be due to cross-cultural limitations of diagnostic tools reporting biases, and differences in socio-economic environments. In every instance, higher percentages of PMTCT uptake were linked to the understanding of the PMTCT approach. This is consistent with a study by, which discovered that providing well-integrated PMTCT services, including patient counselling, is an effective way to prevent HIV MTCT noted that mothers are more adherent to PMTCT services, such as taking infant and maternal ART when they deliver in health facilities, as opposed to those who do not.^12,18 Considering the dual risk of foetal infection with HIV and maternal death, skilled delivery is imperative for expectantly infected women. In the same breadth, Low-quality maternity services, lack of drugs, and provider's attitude often affect the use of facilities.¹⁵ HIV-positive expectant women's attitudes toward healthcare providers and the availability of medical supplies and appliances determine whether to take up PMTCT.¹⁶ Knowledge and Integration of FP and VCT, PMTCT, and ART Programs helps the mothers identify existing FP information and services as well as determine their desires and attitudes for family planning within the context of VCT, PMTCT, and ART. This integration in addition helps identify operational barriers, gaps, and constraints affecting the provision of family planning.²⁸ In this study delivering in health facilities, modified infant feeding practices, early infant diagnosis of HIV, and ARVs for children had statistically significant associated with knowledge.

Limitations

The findings of this study could be affected by several limitations. The nature of data collection could be affected by nonresponse bias. Some mothers still have negative perceptions about HIV and AIDS and therefore were not free to give out information, but rather felt we were disturbing them. The study encountered a small percentage of non-response bias but was minimized by the recruitment of more subjects into the study.

CONCLUSION

The uptake of PMTCT services among postnatal HIV-positive mothers in selected hospitals in Mombasa County was very high meaning that postnatal HIV-positive women embraced the PMTCT interventions. The respondents had adequate knowledge concerning PMTCT services including interventions. It's important to raise awareness of how HIV infection can lead to issues such as intrapartum and postpartum difficulties in seropositive pregnant women. Early identification and treatment of HIV can reduce these risks.

ACKNOWLEDGEMENTS

Authors would like to thank youths who comprised study population and openly contributed to their PMTCT. Authors acknowledge the Chief Administrator of Mombasa County Referral Hospital, Dr. Iqbal Khandwalla, for permitting to conduct research within the hospital's premises.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Preventing Mother-to-Child Transmission of HIV, HIV/AIDS Sudan Fact Sheet D. Available at: https://www.who.int. Accessed on 20 January 2024.
2. 2. Velapi L, Mayers PM, Frantz J. Experiences of Mothers Living With HIV in a South African Prevention of Mother-to-Child Transmission of HIV Programme: A Qualitative Descriptive Study. J Assoc Nurses AIDS Care. 2023;34(2):188-97.
3. 3. What countries need: Investments needed for 2010 targets. Available at: https://data.unaids.org/pub/report/2009/jc1681_what_countries_need_en.pdf. Accessed on 20 January 2024.
4. 4. Astawesegn FH, Stulz V, Agho KE, Mannan H, Conroy E, Ogbo FA. Prenatal HIV Test Uptake and Its Associated Factors for Prevention of Mother to Child Transmission of HIV in East Africa. Int J Environ Res Public Health. 2021;18(10):5289.
5. 5. Kumari A, Kumar R. Fetal Outcome in HIV Positive Women at Tertiary Centre. IJOSR. 2017;5:2015-18.
6. 6. Okal JO, Sarna A, Lango D, Matheka J, Owuor D, Kinywa EA, Kalibala S. Client Experiences in a Mobile-Phone Counseling Intervention for Enhancing Access to Prevention of Mother To-Child Transmission (PMTCT) Services in Kenya. Front Glob Womens Health. 2022;3:785194.
7. 7. Saka AO, Onyeneho CA, Ndikom CM. Perception and utilization of prevention of mother-to-child transmission of human immunodeficiency virus (HIV) services among women living with HIV. Eur J Midwifery. 2021;5:41.
8. 8. Mbonye AK, Hansen KS, Wamono F, Magnussen P. Barriers to prevention of mother-to-child transmission of HIV services in Uganda. J Biosoc Sci. 2010;42(2): 271-83.
9. 9. Current HIV prevalent in Kenya, prevention, and control. Available at: https://hivpreventioncoalition.unaids.org/resources/kenya-2023-hiv-prevention-scorecard. Accessed on 20 January 2024.
10. 10. Mnyani CN, Tait CL, Peters RPH, Struthers H, Violari A, Gray G, Buchmann EJ, Chersich MF, McIntyre JA. Implementation of a PMTCT programme in a high HIV prevalence setting in Johannesburg, South Africa: 2002-2015. South Afr J HIV Med. 2020;21(1):1024.
11. 11. Matseke MG, Yonga AM, Kiss L, Onarheim KH. A systematic review of the effects of intimate partner violence on HIV-positive pregnant women in sub-Saharan Africa. BMC Public Health. 2022;22(1):220.
12. 12. Jones DL, Rodriguez VJ, Soni Parrish M, Kyoung Lee T, Weiss SM, Ramlagan S, et al. Maternal and infant antiretroviral therapy adherence among women living with HIV in rural South Africa: a cluster randomised trial of the role of male partner participation on adherence and PMTCT uptake. Sahara J. 2021; 18(1):17-25.
13. 13. Namara-Lugolobi E, Namukwaya Z, Owor M, Ouma J, Namale-Matovu J, Nakabiito C, et al. Twenty years of Prevention of Mother to Child HIV Transmission: research to implementation at a national referral hospital in Uganda. Afr Health Sci. 2022;22:22-33.
14. 14. Hamilton ARL, le Roux KWDP, Young CW, Södergård B. Mentor Mothers Zithulele: exploring the role of a peer mentorship programme in rural PMTCT care in Zithulele, Eastern Cape, South Africa. Paediatr Int Child Health. 2020;40(1):58-64.
15. 15. Zegeye B, Ahinkorah BO, Ameyaw EK, Seidu AA, Olorunsaiye CZ, Yaya S. Women's decision-making power and knowledge of prevention of mother to child transmission of HIV in sub-Saharan Africa. BMC Womens Health. 2022;22(1):115.
16. 16. Aizire J, Fowler MG, Coovadia HM. Operational issues and barriers to implementation of prevention of mother-to-child transmission of HIV (PMTCT) interventions in Sub-Saharan Africa. Curr HIV Res. 2013;11(2):144-59.
17. 17. Musarandega R, Robinson J, Sen PD, Hakobyan A, Mushavi A, Mahomva A, Woelk G. Using the critical path method to rollout and optimise new PMTCT guidelines to eliminate mother-to-child transmission of HIV in Zimbabwe: a descriptive analysis. BMC Health Serv Res. 2020;20(1):1042.
18. 18. Ajewole OJ, Sparks BL, Omole OB. Uptake and factors that affect enrolment into the prevention of mother-to-child transmission of human immune-deficiency virus programme in rural Limpopo Province. S Afr Fam Pract. 2013;55(6):555-60
19. 19. Gourlay A, Wringe A, Todd J, Cawley C, Michael D, Machemba R, et al. Uptake of services for prevention of mother-to-child transmission of HIV in a community cohort in rural Tanzania from 2005 to 2012. BMC Health Serv Res. 2016;16:4.
20. 20. Ongaki D, Obonyo M, Nyanga N, Ransom J. Factors Affecting Uptake of PMTCT Services, Lodwar County Referral Hospital, Turkana County, Kenya, 2015 to 2016. J Int Assoc Provid AIDS Care. 2019.
21. 21. Boateng D, Kwapong GD, Agyei-Baffour P. Knowledge, perception about antiretroviral therapy (ART) and prevention of mother-to-child-transmission (PMTCT) and adherence to ART among HIV positive women in the Ashanti Region, Ghana: a cross-sectional study. BMC Womens Health. 2013;13(1):2.
22. 22. Deressa W, Seme A, Asefa A, Teshome G, Enqusellassie F. Utilization of PMTCT services and associated factors among pregnant women attending antenatal clinics in Addis Ababa, Ethiopia. BMC Pregnancy Childbirth. 2014;14:328.
23. 23. Cherie S, Workie H, Kassie T, Bitew A, Samuel T. Pregnant Women's Knowledge, Attitude, and Practice Towards the Prevention of Mother to Child Transmission of HIV/AIDS in Dil Chora Referral Hospital, Dire Dawa, Eastern Ethiopia: A Cross-Sectional Study. HIV AIDS. 2022;14:45-60.
24. 24. Harms G, Schulze K, Moneta I, Baryomunsi C, Mbezi P, Poggensee G. Mother-to-child transmission of HIV and its prevention: awareness and knowledge in Uganda and Tanzania. Sahara J. 2005;2(2):258-66.