NON ADHERENCE TO PMTCT TREATMENT AND LOSS TO FOLLOW UP OF HIV POSITIVE MOTHERS AND BABIES IN MOMBASA COUNTY, KENYA

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TABLE OF CONTENTS

DECLARATION…………………………………………………………………………………………………. ii

DEDICATION……………………………………………………………………………………………………. iii

ACKNOWLEDGEMENTS………………………………………………………………………………….. iv

TABLE OF CONTENTS………………………………………………………………………………………. v

LIST OF TABLES…………………………………………………………………………………………….. viii

LIST OF FIGURES…………………………………………………………………………………………….. ix

DEFINITION OF TERMS……………………………………………………………………………………. x

ABBREVIATIONS   AND  ACRONYMS……………………………………………………………. xi

ABSTRACT………………………………………………………………………………………………………. xii

CHAPTER ONE: INTRODUCTION………………………………………………………………….. 1

1.6.2 Specific objective…………………………………………………………………………………….. 7

CHAPTER TWO: LITERATURE REVIEW……………………………………………………. 10

CHAPTER THREE :MATERIALS AND METHODS…………………………………….. 23

CHAPTER FOUR: RESULTS………………………………………………………………………….. 29

CHAPTER FIVE:DISCUSSIONS, CONCLUSIONS AND RECOMMENDATIONS….. 39

REFERENCES………………………………………………………………………………………………… 46

APPENDICES………………………………………………………………………………………………….. 52

APENDIX I: Map of Mombasa county showing study area…………………………………….. 52

APPENDIX II: Place of delivery of the baby………………………………………………………… 53

APPENDIX III: Consent form in English…………………………………………………………….. 54

APPENDIX IV: Consent form in Kiswahili………………………………………………………….. 56

APPENDIX V: Structured interview schedule for mothers…………………………………….. 58

APPENDIX VI: Research authorization……………………………………………………………….. 65

LIST OF TABLES

Table 4.1: Socio Demographic and economic characteristics of the HIV positive Postnatal mothers…………………………………………………………………………………………………………. 29

Table 4.2: PMTCT services accessed  by HIV positive postnatal mothers…………………. 30

Table 4.3: Adherence to PMTCT treatment………………………………………………………….. 31

Table 4.4: Socioeconomic and demographic  characteristics and  adherence to PMTCT treatment  32

Table 4.5: Maternal and new-born practices in relation to  PMTCT guidelines………….. 34

Table 4.6: Reasons for not taking ARV in labour…………………………………………………. 35

Table 4.7: Postnatal clinic appointments……………………………………………………………….. 36

Table 4.8: Access to ARVs…………………………………………………………………………………. 37

LIST OF FIGURES

Figure 1.1: Conceptual Framework……………………………………………………………………….. 9

Figure 4.1: Knowledge of effects of not taking the antiretroviral medication as Prescribed…        38

DEFINITION OF TERMS

Non-adherence to PMTCT Treatment In this study, non-adherence was defined as

mother and/or infant not ingesting single- dose nevirapine at the recommended time or not at all and adherence as mother–infant pairs who ingested it as recommended.

Disclosure                                                       Revealing HIV positive status to family and friends

EMCT of HIV                                               Reduction of transmission to such a low level that it no longer constitutes a public health problem.

Largely married                                            This includes mothers who are married, are co-habiting or have a single steady sexual partner.

Non Disclosure                                              Not having revealed HIV positive status to family and friends.

Postnatal Mother                                            A mother who gave birth to a baby within the last two years.

Single mother                                                 Includes not married, separated, divorced and widows.

ABBREVIATIONS AND ACRONYMS

3TCLamivudine
AIDSAcquired Immune Deficiency Syndrome
ARTAntiretroviral Therapy
ARVAntiretroviral drugs
AZTZidovudine
CDCCenter for disease prevention and control
CD4 cellslymphocytes that protect the body from infection
EMCTElimination of Mother to Child Transmission
EFVEfavirenz
FANCFocused Antenatal Care
FTCEmtricitabine
GoUGovernment of Uganda
HIVHuman Immune Deficiency Virus
KDHSKenya Demographic health Survey
MDGMillennium Development Goals
MoHMinistry of Health
NASCOPNational AIDS Control Council
NVPNevirapine
PCRPolymerase Chain Reaction
PMTCTPrevention of Mother To child transmission
TDFTedinofor
UNAIDSJoint United Nations Programme on HIV/AIDS
VCTVoluntary Counseling and Testing
WHOWorld Health Organization

ABSTRACT

Kenya has more than 2.5 million people living with HIV and AIDS. Mombasa County had a prevalence rate of 7.8% in the year 2009. Globally 390,000 babies were infected with HIV in the year 2010 through mother to child transmission. In Kenya an estimated 37,000 to 40, 000 infants are infected annually in utero. This could be due to loss to follow up and non-adherence to ARVs and Prevention of Mother to Child Transmission (PMTCT) guidelines. The World Health Organization (WHO) recommends Option B triple therapy ART regimens for pregnant women who test HIV positive. The HIV positive mother is given ART for life regardless of the CD4 count or WHO clinical staging. The infant is given AZT or NVP for six weeks after birth if not breastfeeding. In coast province Kenya, only 45.6 % of women were delivered by a skilled health worker in the year 2009. One way to attain high coverage is to give Nevirapine pill to each HIV positive woman in advance to be kept at home and taken at the start of labour and NVP syrup for the baby. The current study investigated factors that contribute to loss to follow up among 322 HIV positive mothers and babies on PMTCT treatment in Mombasa County. A descriptive cross sectional survey was carried out, purposive sampling was done. Of the respondents who were tested 40%, were not aware that they had been tested for HIV in the antenatal clinic. Majority (61 %) of mothers were given the ARVs to keep at home antenatally .Minority of the mothers (41%) did  not take the prescribed antiretroviral pills when they gave birth, while 69.9 % of babies were not given the prescribed ARV syrup due to fear of stigma and discrimination. Non adherence was associated with socio demographic characteristic of youth aged below 35 years, (88.2 %) no high school education (64.3%) and home deliveries (26.4%). Only 34.8% were given correct postnatal clinic return dates. In conclusion, some of the respondents did not adhere to PMTCT treatment due to fear of stigma and discrimination, home delivery, young age and no high school education. The study recommends that health workers should do HIV pretest and PMTCT adherence counseling to all antenatal mothers individually, to include importance of hospital delivery, postnatal and comprehensive clinic appointment dates and education of traditional birth attendants to improve adherence rates.

CHAPTER ONE: INTRODUCTION

            Background information

The National Acquired Immune Deficiency Syndrome and Sexually Transmitted Infection Control Programme (NASCOP) in Kenya through its Prevention of Mother to Child Transmission (PMTCT) initiative, tests antenatal mothers routinely for the presence of HIV as part of the antenatal profile requirements (MoH, 2012). The PMTCT prongs are: Prevention of HIV in women, prevention of unwanted pregnancy, reduction of HIV transmission antenatally, in labour and during breast feeding period and finally support to the HIV positive woman and her family.

HIV testing methods used include Voluntary Testing and Counseling (VCT), Provider initiated testing and counseling (PITC), and Diagnostic testing and counseling (DTC). Mothers who test HIV positive are started on antiretroviral medication either up to the end of the breastfeeding period (Option B) or option B+ where the HIV positive mother is given antiretroviral medication for life regardless of the CD4 count or clinical staging (WHO, 2010). Once they have taken the Nevirapine during labour, most mothers are lost to follow up (McIntyre, 2005). Prevention of Mother to Child Transmission (PMTCT) guidelines released by World Health Organization (WHO) in 2015 recommend Option B+ Antiretroviral Therapy (ART) regimens for pregnant women who test HIV positive: Zidovudine (AZT)+ Lamivudine (3TC) + Nevirapine (NVP) or AZT +3TC + Efavirenz (EFV) (WHO, 2012). The infant is given AZT or NVP for six weeks after birth if not breastfeeding.