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Introduction: Facility-based assessments of prevention of mother-to-child HIV transmission (PMTCT) programs may overestimate population coverage. There are few community-based studies that evaluate PMTCT coverage and uptake. Methods: During 2011, a cross-sectional community survey among women who gave birth in the prior year was performed using the KEMRI-CDC Health and Demographic Surveillance System in Western Kenya. A random sample (n = 405) and a sample of women known to be HIV-positive through previous home-based testing (n = 247) were enrolled. Rates and correlates of uptake of antenatal care (ANC), HIV-testing, and antiretrovirals (ARVs) were determined. Results: Among 405 women in the random sample, 379 (94%) reported accessing ANC, most of whom (87%) were HIV tested. Uptake of HIV testing was associated with employment, higher socioeconomic status, and partner HIV testing. Among 247 known HIV-positive women, 173 (70%) self-disclosed their HIV status. Among 216 self-reported HIV-positive women (including 43 from the random sample), 82% took PMTCT ARVs, with 54% completing the full antenatal, peripartum, and postpartum course. Maternal ARV use was associated with more ANC visits and having an HIV tested partner. ARV use during delivery was lowest (62%) and associated with facility delivery. Eighty percent of HIV infected women reported having their infant HIV tested, 11% of whom reported their child was HIV infected, 76% uninfected, 6% declined to say, 7% did not recall; 79% of infected children were reportedly receiving HIV care and treatment. Conclusions: Community-based assessments provide data that complements clinic-based PMTCT evaluations. In this survey, antenatal HIV test uptake was high; most HIV infected women received ARVs, though many women did not self-disclose HIV status to field team. Community-driven strategies that encourage early ANC, partner involvement, and skilled delivery, and provide PMTCT education, may facilitate further reductions in vertical transmission.
A cross-sectional community-level survey assessing knowledge and uptake of PMTCT services among women of child-bearing age was performed March – June, 2011 in the Kenya Medical Research Institute (KEMRI) and US Centers for Disease Control (CDC) Health and Demographic Surveillance System (HDSS) area in Nyanza Province, Kenya. The HDSS covers 385 villages with a population of approximately 220,000. Three regions situated in Siaya County make up this area: Karemo, Gem and Asembo. [25] All three regions are rural. The HDSS was launched in September 2001 by the US Centers for Disease Control and Prevention (CDC) in collaboration with the Kenya Medical Research Institute (KEMRI) and serves as a community-based platform. The HDSS provides demographic and health information as well as disease- or intervention-specific information. Since its inception, the HDSS has collected 13 years of population-level data. Home-based HIV counseling and testing (HBCT) of the HDSS population has been conducted since 2008, but had not been implemented in all areas at the time of the study. The HDSS area includes 41 health facilities that provide care to pregnant women. Women, maternal age 14 years and older (mothers 14–17 are considered emancipated minors), who were residents in the HDSS area, and had delivered a baby within the previous year (January to December 2010) were recruited. Residency was defined as having lived in the area for at least 4 consecutive months. We leveraged existing HDSS program data to identify and recruit two groups representing two target populations for prevention services: a random community sample to assess factors influencing uptake of general services (access to ANC and maternal HIV testing); and a second sample of HIV infected women, known via previous home-based testing and counseling in the region, to assess factors influencing uptake of HIV-specific services (use of ARVs and infant HIV testing). The same inclusion criteria applied to both general community and HIV-positive groups, with the addition that women in the HIV-positive group must have completed HIV-testing prior to the delivery of the infant. Sampling was limited by the number of women meeting recruitment criteria in the HDSS database. We were able to generate a random list of 523 women from non-HBCT areas to represent a general community assessment of ANC and HIV-testing uptake. In HBCT areas, only 275 women were HIV positive, thus all HIV positive mothers who were diagnosed prior to delivery were approached. Trained fieldworkers were assigned a list of names and locations for all selected participants. Village reporters assisted fieldworkers to locate the mother participant and introduce the study. Fieldworkers administered surveys and recorded GPS location on hand-held PDAs using electronic forms (Pendragon Software Corporation, Buffalo Grove, IL); paper forms were used as a back-up. Mothers’ surveys were adapted from clinic-based surveys used previously in this region [24]. Women were surveyed regarding their knowledge, opinions and use of ANC and PMTCT services at last pregnancy. Outcomes of interest included self-report of uptake of ANC, HIV testing, maternal ARVs for PMTCT, infant testing, and infant ARVs. Potential cofactors assessed included demographics, educational achievement, and marital status, as well as knowledge about HIV and disease transmission. Due to limitations in determining income through household surveys, asset-based indicators (ownership of goods, including mobile phones, cattle, television or refrigerator, and roof type) were used as measures of socioeconomic status. [26], [27] Fieldworkers were not informed of HIV status of participants, thus participant self-reported HIV status was used. In 2010, Kenya national PMTCT guidelines adopted WHO PMTCT Option A (zidovudine during pregnancy with infant nevirapine during breastfeeding for women without advanced HIV, or triple-drug antiretroviral therapy for women with advanced disease) with a provision to implement Option B (triple-drug antiretroviral therapy for all women, stopping after breastfeeding for those without advanced disease) in higher resource systems. As national adoption of new guidelines was slow, and only half of national facilities offered PMTCT, [12] we chose to assess self-report of any maternal ARV uptake at each of three time-points: antenatal, perinatal, and postpartum. Descriptive proportions of those accessing services in the PMTCT cascade were generated. Data analysis utilized chi-square analyses with Fisher’s exact tests for comparison of proportions using STATA SE version 11 (STATACorp, College Station, Texas). Wilcoxon Mann-Whitney tests were used for comparisons where continuous data were not normally distributed. Multivariate analysis using generalized linear models further assessed adjusted prevalence ratios of uptake. A priori covariates of age and education level were included in the model with correlates identified in univariate analyses. Variables were retained in the model if they were significantly associated with the outcome and/or if their inclusion substantially changed the estimates by 10%. Analysis was modeled to assess key steps in the PMTCT cascade: correlates of ANC attendance were assessed among women in the community sample (n = 405); correlates of HIV testing were assessed among women attending ANC with unknown or previously negative HIV status (n = 362); and correlates of maternal and infant ARV uptake were assessed among self-identified HIV-positive women (n = 216). Prior to study start, community engagement activities were held targeting the area senior health officials, the local community advisory board, the village reporters, chiefs and assistant chiefs. Written informed consent was obtained from all study participants, both to be interviewed and also to have their data from these surveys linked to their HDSS record. In Kenya, women with pregnancy are considered emancipated and were therefore able to consent to study participation without parental assent. All study procedures, including enrollment of emancipated minors, were approved by the University of Washington Institutional Review Board (#36022) and the Kenya Medical Research Institute Ethical Review Committee (#1714). Written permission was also received from provincial medical and public health offices.
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