Intra-facility linkage of HIV-positive mothers and HIV-exposed babies into HIV chronic care: Rural and urban experience in a resource limited setting

Introduction: Linkage of HIV-infected pregnant women to HIV care remains critical for improvement of maternal and child outcomes through prevention of maternal-to-child transmission of HIV (PMTCT) and subsequent chronic HIV care. This study determined proportions and factors associated with intra-facility linkage to HIV care and Early Infant Diagnosis care (EID) to inform strategic scale up of PMTCT programs. Methods: A cross-sectional review of records was done at 2 urban and 3 rural public health care facilities supported by the Infectious Diseases Institute (IDI). HIV-infected pregnant mothers, identified through routine antenatal care (ANC) and HIV-exposed babies were evaluated for enrollment in HIV clinics by 6 weeks post-delivery. Results: Overall, 1,025 HIV-infected pregnant mothers were identified during ANC between January and June, 2012; 267/1,025 (26%) in rural and 743/1,025 (74%) in urban facilities. Of these 375/1,025 (37%) were linked to HIV clinics [67/267(25%) rural and 308/758(41%) urban]. Of 636 HIV-exposed babies, 193 (30%) were linked to EID. Linkage of mother-baby pairs to HIV chronic care and EID was 16% (101/636); 8/179 (4.5%)] in rural and 93/457(20.3%) in urban health facilities. Within rural facilities, ANC registration <28 weeks-of-gestation was associated with mothers' linkage to HIV chronic care [AoR, 2.0 95% CI, 1.1-3.7, p=0.019] and mothers' multi-parity was associated with baby's linkage to EID; AoR 4.4 (1.3-15.1), p=0.023. Stigma, long distance to health facilities and vertical PMTCT services affected linkage in rural facilities, while peer mothers, infant feeding services, long patient queues and limited privacy hindered linkage to HIV care in urban settings. Conclusion: Post-natal linkage of HIV-infected mothers to chronic HIV care and HIV-exposed babies to EID programs was low. Barriers to linkage to HIV care vary in urban and rural settings. We recommend targeted interventions to rapidly improve linkage to antiretroviral therapy for elimination of MTCT.

In a descriptive cross-sectional review of health care facility records at selected urban and rural IDI-supported facilities, clients enrolled into the PMTCT programs between January and June 2012, were evaluated for enrollment into chronic HIV care clinics for mothers and early infant diagnosis (EID) by six weeks post-delivery. This study was undertaken within the Infectious Diseases Institute (IDI) outreach project for health systems' strengthening of HIV/AIDS care programs at lower-level health care facilities in Kampala city (urban) and Kibaale district (rural mid-western Uganda). The IDI-supported facilities offer free health services including chronic HIV care and antiretroviral therapy (ART), TB/HIV co-infection services, ANC, labor and delivery services, ART for PMTCT and EID for HIV-exposed babies, provided within the national health care structure. All HIV-positive pregnant mothers are registered daily in ANC registers at their first ANC visit. Registered mothers are referred to return for enrolment at the next HIV clinic day (thrice a week to once a month depending on the total HIV patient load at the facility). In urban facilities patients received referral letters and guidance by a mother who had gone through the system before (peer mother). In rural facilities, mothers received referral letter and directions to the HIV clinic. Upon honoring the referral to HIV clinic, pregnant mothers are registered in the HIV clinic pre-ART registers at the first visit. On the same day, pre-ART mothers are initiated on cotrimoxazole prophylaxis and ART (if CD4 counts are ≤350 cells/ul) and added to the ART register. All HIV-infected mothers are expected to attend at least 4 ANC visits, as recommended by the MCH integrated national guidelines on ART and PMTCT, and independent HIV clinic visits. At delivery, mothers receive a post natal care (PNC)-appointment and a referral of the baby for EID, for presentation at six weeks. Mothers receive referral letters and directions to the respective PNC and EID clinics that run independently. After six weeks post-delivery, mothers return for a PNC visit where family planning, routine immunization and growth monitoring are done. On a different day, the mother brings her baby for registration into the EID program, where babies are registered using the mother's name and address. Among the IDI-supported districts, Kampala, the capital city, was selected to represent the urban setting while Kibaale district was selected randomly out of the 7 rural IDI-supported districts. In Kampala, two HIV/AIDS care facilities (Kawempe HC IV and Komamboga HC III) with the largest numbers of mothers, were conveniently selected out of eight IDI-supported facilities and in mid-western Uganda, three largest rural facilities (Kagadi Hospital, Kibaale HC IV and Nyamarwa HC III), were conveniently selected out of 22 rural IDI-supported HIV/AIDS care facilities. Pre-tested, pre-coded data extraction tools were used to collect and track demographic and clinical data for enrolled HIV-infected mothers and HIV-exposed infants recorded in the ANC, pre-ART and EID registers. Using mothers' names and at least 2 other demographic identifiers such as age and address, mothers in the ANC register were tracked for enrolment in the ART register and mother's name was used to track HIV-exposed infants for registration in the EID registers. The variables recorded included mothers' age, parity, access to a phone contact, gestation age at ANC registration, ART status, date of ART initiation, baby's EID registration status and date of registration, as well as mother-baby HIV clinic registration. Intra-facility linkage of HIV-infected mothers to chronic HIV care, was defined as the proportion of HIV-positive mothers recorded in the ANC and labor registers (for mothers whose first visit occurred during labor), that appeared in the facility pre-ART register and had a clinic number with at least one clinical visit recorded by six weeks post-delivery. Intra-facility linkage of HIV-exposed babies to the EID program was defined as the proportion of babies born to HIV-infected mothers (as per ANC and labor registers), that were registered in the facility EID register with at least one clinical visit recorded by a clinician, by six weeks post-delivery. Intra-facility linkage of mother-baby pairs was defined as the proportion of mother-baby pairs (identified from the ANC and labor registers), that had the HIV-infected mother registered in the HIV clinic and the baby registered in the EID program by 6 weeks post-delivery. To assess factors associated with intra-facility linkage to HIV chronic care and EID, a pre-tested self-administered questionnaire, with open-ended questions, was administered to health care providers (midwives, nurses, doctors, clinical officers, laboratory staff, in the ANC, postnatal, labor, immunization, EID clinics) including facility heads as key informants to determine health worker perspectives of promoters and hindrances to linkage of mothers and babies within their respective health care facilities. In addition, ten focus group discussions (FGD) were conducted among health workers to further understand health worker perspectives on determinants and hindrances to intra-facility linkage to chronic HIV care and EID following PMTCT interventions at the respective health care facilities. Each FGD consisted of 4–8 people including a nurse, midwife, doctor, peer mother, laboratory technicians and clinical officers. The FGD guide included pre-determined themes that were developed through monitoring and evaluation meetings by the IDI outreach team in charge of PMTCT program implementation. The themes covered health worker factors, health system factors and patient factors affecting linkage of mothers and babies to HIV care after PMTCT, from the perspectives of health workers. All FGDs occurred concurrently at different sites and each FGD had a leader and a note taker. This work was done in compliance with the Helsinki Declaration (http://www.wma.net/en/30publications/10policies/b3/index.html), and all health workers (key informants and FGD members) provided verbal informed consent. Ethical approval was provided by the Makerere University College of Health Sciences, School of Medicine review board. Quantitative data was entered using Microsoft Excel and exported to STATA version 11.0 for analysis. Demographic and clinical data were summarized using frequencies and medians. Proportions of intra-facility linkage of HIV-infected mothers to HIV care, HIV-exposed children to EID and mother-baby pairs were presented as per case definitions. Student T test was used to compare continuous variables and Pearson's Chi square test was used to compare categorical variables among individuals linked and those that were not linked to HIV care and EID programs by six weeks post-delivery. All variables were entered in a stepwise backward multivariate logistic regression model to determine predictors of getting linked to HIV care and EID within each of the studied health care facilities. P-values <0.05 were considered statistically significant. Qualitative data from FGDs and key informant questionnaires was analyzed using the principles of thematic analysis [16], [17]. Data content was analysed manually according to the predetermined themes; summarised in tables and quotes were reported verbatim. The analysis themes included motivators and hindrances to intra-facility linkage to HIV care such as health worker, health systems and social support factors, as perceived by the health workers. Content analysis included access to services, health worker competence, as well as patients' perceptions and social structure. All data was stored securely with access limited to the study team.

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• Dima Health