Only 4% of HIV-positive pregnant women estimated as needing ART for their own health (CD4 cell counts under 350 cells/mm3) started ART within six months of getting an HIV diagnosis according to a retrospective study of routine hospital data from Naivasha and Gilgil, two government hospitals in the Rift Valley province of Kenya published in the advanced online edition of the Journal of Acquired Immune Deficiency Syndromes.
Between testing HIV positive in a ‘pregnancy-related service’ (antenatal or delivery services) and linkage to HIV-related care and treatment (the prevention of mother-to-child transmission (PMTCT) continuum of care cascade) patient loss was considerable at each step, in line with the few studies that have looked at this important issue.
Only 17.2 % (153/892) and 35.4% (84/237) of the women registered at an HIV clinic within six months of diagnosis at Naivasha and Gilgil hospitals, respectively. Of these the numbers getting CD4 cell count testing was 68% (99/153) and 43% (36/84), respectively; of which only 40% and 27% of eligible women started ART.
Women who came for only one pregnancy-related service had the lowest level of registration at the HIV clinic.
ART during pregnancy and breastfeeding significantly reduces mother-to-child transmission of HIV. However, little attention has been focused on the role of ART in improving a mother’s own survival as well as ensuring the child will grow up with a mother.
While there is evidence that after diagnosis many pregnant women do not access long-term care and treatment little is known why this is happening.
The authors chose to determine the drop-out rates among pregnant women from when they test HIV positive within a pregnancy-related service in Kenya to when they access services; and, to identify those factors linked to service uptake to inform the design of interventions minimising client drop-out.
Standard care in Kenya for all women attending pregnancy-related services whose HIV status is unknown or who tested negative more than three months prior is to be offered provider initiated HIV testing and counselling. ART is provided free to all in need.
According to a 2008-2009 survey 92% of pregnant women got antenatal care (ANC) from a medical professional; 56% of women attending ANC had been counselled, tested and got their HIV results.
Since 2005 national guidelines have recommended lifelong ART for pregnant women with CD4 cell counts under 350 cells/mm3; and since 2009 for those with CD4 counts above 350 cells/mm3 short course of ART for PMTCT.
The authors stress policies are only as effective as the health system’s capacity to deliver the recommended interventions.
The hospitals were chosen as a convenience sample because they were government hospitals without a lot of external support. All women testing positive within pregnancy-related services are supposed to be referred immediately to the HIV clinic, on-site in both hospitals. At Naivasha it is a two-minute walk from ANC and a 5-10 minute walk at Gilgil.
The cohorts included all women aged 15 or over recorded as being diagnosed with HIV in pregnancy-related services between January 1, 2008 and June 30, 2010.
Six months of follow-up time for each woman with corresponding demographic information from her first recorded visit to pregnancy-related services and uptake of HIV-related services was assessed for each hospital.
Low levels of registration among women who only went to Naivasha for delivery may reflect the high levels of migrant labour there, note the authors so highlighting the challenge of providing long-term care to mobile populations.
In both hospitals women who had multiple appointments, and at Gilgil only those in their first pregnancy were more likely to register at the HIV clinic.
Contrary to previous research the absence of an association between transport costs and long travel times as significant barriers to accessing pregnancy and HIV-related services is noteworthy, the authors state.
While pregnancy-related services were closer to the HIV clinic at Naivasha than at Gilgil it did not result in higher registration. The authors suggest that a greater frequency of client escorts at Gilgil and contrary to policy of nurses at Naivasha reporting “that it is often not worth registering someone during their first visit as many women never returned to the clinic” may help explain this.
Apart from escorting clients there was no way of nurses to know whether a woman had registered following referral or conversely for nurses in the HIV clinic to know when a woman had been referred.
The authors suggest in hospitals with computer networks tracking systems could be set up. In other settings regular meetings between health workers could be set up to track referral outcomes using duplicate referral forms; one for the client to take to the clinic and the other within the pregnancy-related service and reconciled at the end of the month.
The authors state while the guidelines note counselling should include “information and skill on how to reduce or avoid mother-to-child transmission” they are not told explicitly that ART is critical to PMTCT in women who are HIV positive. They suggest since a woman’s primary concern is the health and wellbeing of her child above her own this may be an important strategy for improving uptake of long-term HIV-related services.
The cost and difficulties of getting CD4 tests added to the low levels of service uptake, the authors note. Free and point-of-care CD4 testing on the same day as the HIV diagnosis could both improve uptake and retention in care, they add, especially among those who are asymptomatic.
Some health care system interventions shown to be effective to improve retention in care for pregnant women with HIV according to the authors include:
Integration of CD4 count testing and starting ART at ANC services
Pregnant women bypassing queues at HIV services
Paying trained staff to work overtime to extend hours of available services
Task shifting
Training new cadres of health workers such as lay counsellors to provide additional counselling to newly diagnosed clients
Peer escorts by women who have recently used PMTCT services.
Data are not from a representative sample of Kenyan health facilities so limiting the generalisation of the findings.
The authors conclude “a striking level of attrition was identified between testing HIV-positive in pregnancy-related services and accessing HIV-related services in the study facilities” highlighting the critical need for “ innovation in service delivery to improve uptake of services [along the PMTCT cascade].”
The study was led by Laura Ferguson of the London School of Hygiene and Tropical Medicine in collaboration with colleagues at the University of Nairobi.
Ferguson L et al. Patient attrition between diagnosis with HIV in pregnancy-related services in Kenya: a retrospective study. Advance online edition JAIDS, doi: 10.1097/QAI.0b013e318253258a, 2012.