Missed Opportunities for Early Infant HIV Diagnosis: Results of A National Study in South Africa

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Abstract

Background:

Services to diagnose early infant HIV infection should be offered at the 6-week immunization visit. Despite high 6-week immunization attendance, the coverage of early infant diagnosis (EID) is low in many sub-Saharan countries. We explored reasons for such missed opportunities at 6-week immunization visits.

Methods:

We used data from 2 cross-sectional surveys conducted in 2010 in South Africa. A national assessment was undertaken among randomly selected public facilities (n = 625) to ascertain procedures for EID. A subsample of these facilities (n = 565) was revisited to assess the HIV status of 4- to 8-week-old infants receiving 6-week immunization. We examined potential missed opportunities for EID. We used logistic regression to assess factors influencing maternal intention to report for EID at 6-week immunization visits.

Results:

EID services were available in >95% of facilities and 72% of immunization service points (ISPs). The majority (68%) of ISPs provide EID for infants with reported or documented (on infant's Road-to-Health Chart/booklet—iRtHC) HIV exposure. Only 9% of ISPs offered provider-initiated counseling and testing for infants of undocumented/unknown HIV exposure. Interviews with self-reported HIV-positive mothers at ISPs revealed that only 55% had their HIV status documented on their iRtHC and 35% intended to request EID during 6-week immunization. Maternal nonreporting for EID was associated with fear of discrimination, poor adherence to antiretrovirals, and inadequate knowledge about mother-to-child HIV transmission.

Conclusions:

Missed opportunities for EID were attributed to poor documentation of HIV status on iRtHC, inadequate maternal knowledge about mother-to-child HIV transmission, fear of discrimination, and the lack of provider-initiated counseling and testing service for undocumented, unknown, or undeclared HIV-exposed infants.

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Most cited references 17

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Official statistics and claims data records indicate non-response and recall bias within survey-based estimates of health care utilization in the older population

Matthias Hunger, Larissa Schwarzkopf, Margit Heier … (2013)

Background The validity of survey-based health care utilization estimates in the older population has been poorly researched. Owing to data protection legislation and a great number of different health care insurance providers, the assessment of recall and non-response bias is challenging to impossible in many countries. The objective of our study was to compare estimates from a population-based study in older German adults with external secondary data. Methods We used data from the German KORA-Age study, which included 4,127 people aged 65–94 years. Self-report questions covered the utilization of long-term care services, inpatient services, outpatient services, and pharmaceuticals. We calculated age- and sex-standardized mean utilization rates in each domain and compared them with the corresponding estimates derived from official statistics and independent statutory health insurance data. Results The KORA-Age study underestimated the use of long-term care services (−52%), in-hospital days (−21%) and physician visits (−70%). In contrast, the assessment of drug consumption by postal self-report questionnaires yielded similar estimates to the analysis of insurance claims data (−9%). Conclusion Survey estimates based on self-report tend to underestimate true health care utilization in the older population. Direct validation studies are needed to disentangle the impact of recall and non-response bias.

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High acceptability of voluntary counselling and HIV-testing but unacceptable loss to follow up in a prevention of mother-to-child HIV transmission programme in rural Malawi: scaling-up requires a different way of acting.

E Bakali, J Kazima, M. Manzi … (2005)

Thyolo District Hospital, rural Malawi. In a prevention of mother-to-child HIV transmission (PMTCT) programme, to determine: the acceptability of offering 'opt-out' voluntary counselling and HIV-testing (VCT); the progressive loss to follow up of HIV-positive mothers during the antenatal period, at delivery and to the 6-month postnatal visit; and the proportion of missed deliveries in the district. Cohort study. Review of routine antenatal, VCT and PMTCT registers. Of 3136 new antenatal mothers, 2996 [96%, 95% confidence interval (CI): 95-97] were pre-test counselled, 2965 (95%, CI: 94-96) underwent HIV-testing, all of whom were post-test counselled. Thirty-one (1%) mothers refused HIV-testing. A total of 646 (22%) individuals were HIV-positive, and were included in the PMTCT programme. Two hundred and eighty-eight (45%) mothers and 222 (34%) babies received nevirapine. The cumulative loss to follow up (n=646) was 358 (55%, CI: 51-59) by the 36-week antenatal visit, 440 (68%, CI: 64-71) by delivery, 450 (70%, CI: 66-73) by the first postnatal visit and 524 (81%, CI: 78-84) by the 6-month postnatal visit. This left just 122 (19%, CI: 16-22) of the initial cohort still in the programme. The great majority (87%) of deliveries occurred at peripheral sites where PMTCT was not available. In a rural district hospital setting, at least 9 out of every 10 mothers attending antenatal services accepted VCT, of whom approximately one-quarter were HIV-positive and included in the PMTCT programme. The progressive loss to follow up of more than three-quarters of this cohort by the 6-month postnatal visit demands a 'different way of acting' if PMTCT is to be scaled up in our setting.

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Reasons for loss to follow-up among mothers registered in a prevention-of-mother-to-child transmission program in rural Malawi.

R. Zachariah, K Kamoto, L Bwirire … (2008)

This study was conducted to identify reasons for a high and progressive loss to follow-up among HIV-positive mothers within a prevention-of-mother-to-child HIV transmission (PMTCT) program in a rural district hospital in Malawi. Three focus group discussions were conducted among a total of 25 antenatal and post-natal mothers as well as nurse midwives (median age 39 years, range 22-55 years). The main reasons for loss to follow-up included: (1) not being prepared for HIV testing and its implications before the antenatal clinic (ANC) visit; (2) fear of stigma, discrimination, household conflict and even divorce on disclosure of HIV status; (3) lack of support from husbands who do not want to undergo HIV testing; (4) the feeling that one is obliged to rely on artificial feeding, which is associated with social and cultural taboos; (5) long waiting times at the ANC; and (6) inability to afford transport costs related to the long distances to the hospital. This study reveals a number of community- and provider-related operational and cultural barriers hindering the overall acceptability of PMTCT that need to be addressed urgently. Mothers attending antenatal services need to be better informed and supported, at both community and health-provider level.

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Author and article information

Journal

Journal ID (nlm-ta): J Acquir Immune Defic Syndr

Journal ID (iso-abbrev): J. Acquir. Immune Defic. Syndr

Journal ID (publisher-id): qai

Title: Journal of Acquired Immune Deficiency Syndromes (1999)

Publisher: JAIDS Journal of Acquired Immune Deficiency Syndromes

ISSN (Print): 1525-4135

ISSN (Electronic): 1944-7884

Publication date (Print): 1 March 2015

Publication date (Electronic): 13 February 2015

Volume: 68

Issue: 3

Pages: e26-e32

Affiliations

[* ]Health Systems Research Unit, Medical Research Council, South African Medical Research Council, Parrowvallei, Cape Town, South Africa;

[† ]School of Public Health, University of the Western Cape, Bellville, South Africa;

[‡ ]UNICEF, New York, NY, USA;

[§ ]Department of Paediatrics and Child Health, Kalafong Hospital, University of Pretoria, Pretoria, South Africa;

[‖ ]ELMA Philanthropies, New York, NY, USA;

[¶ ]School of Public Health, University of the Witwatersrand, Johannesburg, South Africa;

[# ]Centers for Disease Control and Prevention, Pretoria, South Africa;

[** ]Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV/AIDS, Atlanta, GA, USA;

[†† ]Centre for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa; and

[‡‡ ]Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.

Author notes

Correspondence to: Selamawit A. Woldesenbet, MPH, PhD, Health Systems Research Unit, South African Medical Research Council, Francie van Zyl Drive, Parrowvallei, Cape Town 7505, South Africa (e-mail: woldeselam@ 123456gmail.com ).

Article

Publisher ID: QAIV14584 Accession ID: 00019

DOI: 10.1097/QAI.0000000000000460

PMC ID: 4337585

PubMed ID: 25469521

SO-VID: f2486ce0-a64e-4717-b941-8ed7dbf267de

License:

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

History

Date received : 26 June 2014

Date accepted : 05 November 2014

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Keywords: eid service,pict,missed opportunities,hiv-exposed infants,mother-to-child hiv transmission

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Keywords: eid service, pict, missed opportunities, hiv-exposed infants, mother-to-child hiv transmission

Missed Opportunities for Early Infant HIV Diagnosis: Results of A National Study in South Africa

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Most cited references 17

Official statistics and claims data records indicate non-response and recall bias within survey-based estimates of health care utilization in the older population

High acceptability of voluntary counselling and HIV-testing but unacceptable loss to follow up in a prevention of mother-to-child HIV transmission programme in rural Malawi: scaling-up requires a different way of acting.

Reasons for loss to follow-up among mothers registered in a prevention-of-mother-to-child transmission program in rural Malawi.

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