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Background: Women and children in sub-Saharan Africa bear a disproportionate burden of HIV/AIDS. Integration of HIV with maternal and child services aims to reduce the impact of HIV/AIDS. To assess the potential gains and risks of such integration, this paper considers pregnant women’s and providers’ perceptions about the effects of integrated HIV testing and counselling on care seeking by pregnant women during antenatal care in Tanzania. Methods: From a larger evaluation of an integrated maternal and newborn health care program in Morogoro, Tanzania, this analysis included a subset of information from 203 observations of antenatal care and interviews with 57 providers and 190 pregnant women from 18 public health centers in rural and peri-urban settings. Qualitative data were analyzed manually and with Atlas.ti using a framework approach, and quantitative data of respondents’ demographic information were analyzed with Stata 12.0. Results: Perceptions of integrating HIV testing with routine antenatal care from women and health providers were generally positive. Respondents felt that integration increased coverage of HIV testing, particularly among difficult-to-reach populations, and improved convenience, efficiency, and confidentiality for women while reducing stigma. Pregnant women believed that early detection of HIV protected their own health and that of their children. Despite these positive views, challenges remained. Providers and women perceived opt out HIV testing and counselling during antenatal services to be compulsory. A sense of powerlessness and anxiety pervaded some women’s responses, reflecting the unequal relations, lack of supportive communications and breaches in confidentiality between women and providers. Lastly, stigma surrounding HIV was reported to lead some women to discontinue services or seek care through other access points in the health system. Conclusion: While providers and pregnant women view program synergies from integrating HIV services into antenatal care positively, lack of supportive provider-patient relationships, lack of trust resulting from harsh treatment or breaches in confidentiality, and stigma still inhibit women’s care seeking. As countries continue rollout of Option B+, social relations between patients and providers must be understood and addressed to ensure that integrated delivery of HIV counselling and services encourages women’s care seeking in order to improve maternal and child health.
Populated with 44.8 million people and located in east Africa, Tanzania is a low-income country with a per capita gross national income of 540 U.S. dollars [19]. With regards to maternal health, focused antenatal care (FANC) guidelines in 2002 reduced the frequency of facility visits from monthly to a minimum of four times with new counselling and clinical services (Table 2) [20,21]. Between 2005 and 2010, 95.8% of pregnant women in mainland Tanzania made at least one antenatal care visit with skilled providers. Yet, only 42.7% of women in mainland Tanzania made four or more antenatal care visits, and half of them made their first visit during the fifth month of pregnancy [22]. While women can and do access antenatal care in facilities, challenges in terms of continuity and quality remain. Overall, 23.1% of women reported having at least one problem in accessing health care [22]. Integrated HIV and ANC services in Tanzania Source: Adapted from von Both C, Fleba S, Makuwani A, Mpembeni R, Jahn A. How much time do health services spend on antenatal care? Implications for the introduction of the focused antenatal care model in Tanzania. BMC Pregnancy and Childbirth 2006, 6(22). Morogoro is one of 30 regions in Tanzania, located about 200 kilometers southwest of Dar es Salaam [23]. With a population of 2.2 million and a population density of 31 inhabitants per square kilometer, Morogoro region is among Tanzania’s largest and least densely populated regions. According to a 2002 census, more people live in rural areas (73%) than in urban areas (27%) in Morogoro, similar to most regions in Tanzania [24]. Regional averages for education, poverty and care seeking are also similar to national averages. With regards to HIV, 67.1% of women of reproductive age and 49.8% of men between 15–49 in Morogoro have ever tested for HIV, while 5.3% of women of reproductive age and 2.1% of men between the ages of 15–49 are HIV-positive [2]. As part of a three-year evaluation of a maternal and newborn health care program implemented by the Ministry of Health and Social Welfare (MoHSW) and MAISHA through Jhpiego in Morogoro, Tanzania, all 18 government health centers in four rural and peri-urban districts (Gairo, Kilosa,a Morogoro District Council, Mvomero, and Ulanga) were chosen for a cross-sectional health facility assessment. A team of six research assistants received training over six days that included research ethics and techniques, project objectives, overview of instruments, and two days of pilot testing in health care facilities. Data collection proceeded from September to early December 2012. In each health facility, data were collected over a period of two days. Prior to the start of data collection, study personnel visited each health facility in-charge to brief him or her on data collection objectives and coordinate data collection on the days when antenatal and postnatal services were provided (Table 3). At each health facility, the first ten pregnant women attending routine antenatal services were approached for their participation and consent to the study and then subsequently observed and interviewed. Data sources included in MNCH facility survey At least five providers per facility providing antenatal and postnatal services during the day shift were administered a structured quantitative survey. A sub-sample of about three providers per facility were then chosen for in-depth qualitative interviews based on their Jhpiego training, provision of maternal and newborn health services, and years of service. Provider interviews covered topics including antenatal and postnatal service utilization, integration of family planning and HIV services, and linkages to other levels of the health system. Data quality was ensured by two field-based supervisors who provided overarching support to field implementation, including review of completed instruments and conduct of daily debriefings following in-depth interviews. Completed and supervisor-checked questionnaires were sent to Dar es Salaam for data entry and cleaning. Qualitative provider interviews were digitally recorded, transcribed, and translated to English. Team debriefings at midpoint and endpoint of data collection reviewed emerging themes and assessed reliability of data through triangulation. After the midpoint debrief, revised interview guides focusing on emerging themes were implemented for the last seven health facilities visited by the research team. This paper drew primarily from qualitative interviews with pregnant women and antenatal care providers on the topic of integrated HIV testing and counselling services during routine antenatal care. In addition, women’s and providers’ demographic profiles were also included as background information. Thematic qualitative data analysis was performed manually from a database coded and organized by Atlas.ti. Codes were derived from the structure of the interview guide and from themes that emerged during daily, midpoint and endpoint debriefings. Codebook development and coding were undertaken through consensus by a team, including research assistants who conducted data collection and whose work was reviewed by a supervisor. A framework approach [25] was taken in the qualitative portion of the research, utilizing an inductive approach with pre-defined research questions. Preliminary findings from both the quantitative and qualitative analysis were shared with MoHSW and implementing partner for their feedback and review. The study received ethical approval from the Muhimbili University of Health and Allied Sciences (MUHAS) and the Johns Hopkins School of Public Health (JHSPH) Institutional Review Boards. Permission to conduct the study was obtained from MoHSW and from the region and district administration authorities. Individual written consents were obtained from the study participants prior to their participation in the study. All information was kept confidential and anonymous.
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