Factors Influencing ART In PMTCT

Literature Review

Discuss about the Factors Influencing of ART in PMTCT.

Acquired immunodeficiency syndrome (AIDS) is associated with the progressive impairment of the immune system and leads to the serious and late stage complications in the human being. Over the last three decades prevalence of HIV is spread all over the world. According to World Health Organization (WHO) estimate there are approximately 40 million people are living with HIV. In this women population is approximately 16 million and pregnant women population is approximately 1.4 million. These pregnant women have the risk of transmission of HIV to their children. This growing prevalence of HIV in women is due to physiological aspects of women responsible for the susceptibility to infection. Along with this social and psychological vulnerability generated by economic, socio-cultural and legal factors is responsible for prevalence of HIV. WHO also estimated that around 77 % women who were living with HIV received antiretroviral medicine to prevent transmission of HIV to their babies. More than half of the burden of HIV was estimated in the Southern African countries like Botswana, South Africa, Zimbabwe, Swaziland and Namibia. Approximately 20 % of the expectant mothers are generally affected with HIV in these countries and 20 % deaths occurred due to the AIDS (Sharma & Khadhiravan, 2008). In Botswana, approximately 40 % of antennal women were infected with HIV. Out of these, approximately 16 % of infants born with HIV infection. Even though prevalence of AIDS is more in these sub-Saharan African countries, utilization of antiretroviral drugs is not widespread. Different reasons were observed for this low utilization of antiretroviral drugs in these countries and these reasons include cost, logistic and social issues (Yazdanpanah, 2004). It has been observed that high cost of antiretroviral drugs and diagnostic are the main barriers for the prevention of transmission of HIV from mother to child. Other barriers responsible for the prevention of transmission of HIV from mother to child (PMTCT) are lack of national regulatory policy, tariffs and taxation on antiretroviral drugs and lack of international funding for the implementation of antiretroviral drug administration (Attaran & Gillespie-White, 2001).

Even tough, Botswana Government decided to initiate antiretroviral drug therapy for the people in 2000, prevention remains the cornerstone for the national AIDS strategy. In accordance with the 2010 recommendations of the WHO, the Ministry of Health has improved access to ART by expanding eligibility criteria to all adults with CD4 counts ≤ 350 cells/µL. This change is also reflected in pediatric populations; all children ≤ 24 months of age as well as children from 2 – 5 years with CD4 counts ≤ 750 cells/µL or CD4 ≤ 25% will be eligible to begin ART.) . In African countries, Botswana is the first country to initiate programme for the prevention of mother to child transmission in 2001 (Creek et al., 2006). International recommendations for the antiretroviral therapy were not considered for the implementation of antiretroviral therapy in Botswana. These recommendations were non-consideration of the climate, complexity of social and health infrastructure and lifestyle of the people of the Botswana. Along with these government initiatives other stakeholders also participated in the implementation of prevention of mother to child transmission. Bill Gates foundation and major pharmaceutical firm like Merck contributed to the implementation of prevention of transmission from mother to child. Ministry of Education with the collaboration of Stanford University in 2011 launched Teach AIDS software which helps in education of the people to fight against HIV infection. Implementation of Option B+ and prevention of mother to child transmission in Botswana collectedly resulted in the improvement in the reduction of HIV cases (Coutsoudis et al., 2013).

Rationale for study design

It has been well established in the literature that implementation of ART programme successfully resulted in the reduction in the transmission of HIV from mother to child. Health of child is completely dependent on the health of the mother. Survival of the virus responsible for AIDS depends of the health of the mother. If mother health is not good there are more chances of long duration  survival of viruses and transmission to the children. Due to ill health of mother, there is the possibility of the reduced transfer of positive immunity in the children and it results in the increased burden of the mother to children transmission. In Tanzania implementation of prevention of mother to child transmission in collaboration with Option B+ resulted in lessening the transmission of HIV infection from mother to child (Gourlay, et al., 2016). In Nigeria also prevention of mother to child prevention programme of HIV infection was implemented, however this programme faced problems like influence of less education among the population, low employment and the low socioeconomic status of the people. In a study conducted in Ghana, it has been established that lack of knowledge of antiretroviral therapy among women resulted in the inefficient implementation of the PMTCT. Option B+ has been successfully implemented in Malvi for reduction in the HIV transmission (Kim, et al., 2015). However, Option B+ has not been successfully implemented in Botswana because of lack of support for community based therapy for ART, unwillingness of the women to use ART, problems associated with the breastfeeding and lack of qualified human resource for the implementation of the programme.    

In some of the sub-Saharan countries use of ART for PMTCT increased from 15 % in 2005 to 55 % in 2009. However, this rate of increment in the use of ART for PMTCT is not enough in the country like Botswana where prevalence of AIDS is very high (WHO, 2010). From the literature, it is evident that there is the good understanding for the knowledge of barriers for the uptake of ART in PMTCT in general population and however, there is less knowledge about the barriers for uptake of ART in PMTCT in pregnant women (Mills et al., 2006; Posse et al., 2008). In a study conducted in Zimbabwe, it has been established that, replacement of single-dose nevirapine (sdNVP) with modified ART resulted in the reduction of transmission of HIV infection to child in PMTCT (Ciaranello et al., 2013). In studies like Post-Exposure Prophylaxis of Infants (PEPI-Malawi), Breastfeeding, Antiretrovirals, and Nutrition (BAN) study and the 3 parallel randomized trials of Six Weeks Extended Nevirapine (SWEN) exhibited success of ART in PMTCT. In longer duration studies like HIV Prevention Trials Network (HPTN), it has been established that there is no transmission of HIV infection from using ART in PMTCT (Shetty & Maldonado, 2013). Drug Resource Enhancement Against AIDS and Malnutrition (DREAM) study established that there is reduced maternal mortality, premature birth and PMTCT due to the use of ART. Hence, ART should be initiated in the pregnant women at the optimum time to avoid further complications. There is evidence available for the safety of ART in infants, hence pregnant women should not worry about the risk of ART to infants.  ART in PMTCT has been successfully implemented in North America and Europe. As a result, there is the eradication of the HIV in the new born. Women with the positive HIV infection and who met the criteria of number of CD4 cell should start the ART immediately after the positive test. WHO recommended two options for the ART. In Option A, women with HIV infection should start zidovudine during antenatal period and at the time of delivery. Also, these women should take nevirapine every week. In case of infants, nevirapine treatment should start daily from the birth until cessation of breastfeeding. In Option B, women should take three combinations of ART during antenatal period and continue until the cessation if breastfeeding (Shetty & Maldonado, 2013).  

There were the studies and reviews available for the information related to the community based involvement for PMTCT, success and failures of PMTCT and retention of ART therapy in pregnant women (Ferguson et al., 2015; Busza et al., 2012). However, less studies were available for the evaluation of factors influencing uptake of ART in PMTCT. There is urgent requirement to understand the factors responsible for the uptake of ART in PMTCT. Hence, this study is planned to understand the factors responsible for uptake of ART in PMTCT. In this study factors responsible for the uptake of the ART in PMTCT were selected based on the evidence and literature. It is evident from the literature that poor knowledge about the transmission of HIV and role of ART in the PMTCT are responsible for the inefficient implementation of the PMTCT programme. There were also doubt about the effectiveness of ART in the management of AIDS and few women had belief that ART would cause HIV (Watson-Jones et al., 2012; Duff et al., 2010). Psychological factors like shock and depression due to the diseased condition are responsible for the inability to uptake ART in PMTCT (Stinson & Myer, 2012). Stigma related to the disclosure of HIV to the family members and to the community leads to not attending the clinics for ART. As a result, there is the barrier to the implementation of ART in the PMTCT (Laher et al., 2012).  It is also evident from the literature that insufficiency of trained clinical staff for the implementation of ART in PMTCT resulted in the ineffective implementation of the policy. This resulted in the increased number of patients and consequently increased waiting list for the patients, stress on the staff members and failure of the staff members for the implementation of the ART in PMTCT (Sprague et al., 2011; Laher et al., 2012).  It has been well established in the literature that knowledge about the HIV, ART and PTMCT could has positive impact on the socioeconomic status of the people and educational level. Women with higher education were positively responded to the implementation of the ART in PMTCT.

In this project non-experimental and quantitative method will be implemented to collect the information regarding factors influencing uptake of ART on PMTCT. Study design will be descriptive in nature and study duration will be 6 months. This study will be conducted in the Boteti health district in Botswana. This study will be incorporating 500 pregnant women. 500 women will be enough to get the required data. Method of sampling used in this study will be random sampling. Sample size will be determined based on the feasibility of the resources.  This sample size will be optimum for the statistical analysis. These women will be from low, middle and high socioeconomic class. Both the types like educated and uneducated women will be incorporated in this study. For this study 10 facilities will be selected comprising of 6  maternity facilities  and 4 clinics in the Boteti health district in Botswana will be selected. These maternity homes and clinics will comprise of both Government and non-Government organizations. This a analytical cross-sectional investigation will be performed using interviews in different maternity facilities and clinic. Theses 500 women will be allocated to different maternity homes and clinics based on the geographical areas. Allocation of the women to the respective maternity home and clinic will be based on the financial constraints, services available and social support. Inclusion criteria for the selection of pregnant women will be at least one visit to the maternity home or clinic during current pregnancy and these women will be confirmed HIV positive. Exclusion criteria will be women with negative HIV test. Data regarding CD4 cells will be collected from the respective maternity home and clinic. Women with CD4 cell count below 350 cells per microlitre will be considered in the study. Age of women incorporated in the study will be between 18 – 45 years. These women will be approximately distributed equally among first, second and third trimester of the pregnancy. Approximately 33 % women will be there in each population of trimester women. Interviews of these women will be conducted by the trained and experts in the field. For conducting these interviews structured questionnaire will be prepared. This questionnaire will be specifically in the local language so that all the class of women will be comfortable in attending the interview session. Location of the interview will be respective maternity home or clinic. Information about the identity of the participant women will be kept confidential to maintain dignity of the patient. Informed consent will be taken from each women and one of the family members before conducting interview. Approval will be taken from the human sciences research council (HSRC) ethics committee of and Ministry Of Health Botswana Government other health authorities at the district level before conducting the study. These questionnaires will be incorporating questions related to the knowledge related to the HIV and ART, maternal education, psychological issues of women related to the AIDS, social issues of women related to the AIDS, whether women are attending traditional healers and birth attendees and support from the staff in the prevention of PTMCT.

Following will be the representative questions in the questionnaire :

Has you know about HIV/AIDS ?

Has you know about ART ?

Has you used ART ?

Has you know about transmission of HIV to child ?  

Are you depressed due to your HIV infection ?

Are you getting support from your family members from your family and community members in treating HIV infection ?

Are you attending traditional healers during your pregnancy ?

Are you getting enough support and help from health care providers during your treatment for HIV infection ?

Data will be collected twice from a single participant. Initially data will be collected based on the interview without any counseling and second time data will be collected after the completion of counseling about importance of ART and its role in the PMTCT. All the data will be stored as electronic database. Collected data will be presented in the form of arithmetic mean, standard deviation, median and percentage. Collected data will be analyzed using Statistical Analysis System, SAS 9.1 (Peltzer et al., 2011; Stinson et al., 2010; Stringer et al., 2010).

Evaluation of the outcome of the study will be performed based on the collected data. Evaluation will be performed to determine whether collected data will be useful for answering all the questions created at the time of deciding objectives of the study. Collected data will be evaluated to get insight into the validity of assumptions made. Outcome of this study will be useful in implementing the same criteria in the large population of women. Factors which will be responsible as barriers for ART in PTMCT will be managed more effectively so that these factors will not interfere in the implementation of ART in PTMCT. Factors which will be promoting ART in PTMCT will be encouraged to implement in the actual practice. Outcome of this study will also be useful in designing educational programme for pregnant women with HIV infection. Solution or alternatives will be found for factors which will be hindering the implementation of ART in PTMCT. Health care professionals in the nursing home and clinical will be using these findings as evidence and will implement same findings in their maternity homes and clinics. Findings of this study will be definitely useful in controlling progression of HIV through PTMCT. Findings of this study will also useful for Government and regulatory agencies for implementing the uniform cost of ART, so that all the class of women will consume ART without barrier of high cost. Outcome of this study will be useful in initiating counseling programme in the respective society or community. This will be definitely useful in the controlling the social issues in implementing the ART in PTMCT. Due to this study, women with HIV will feel relieved because their identity will be secured and also these women will be getting proper treatment for HIV. This study will be useful in the generation of well qualified human resource for the implementation of the ART in PTMCT. This study will be useful in understanding view of the women with socioeconomic background and different educational level about ART in PTMCT. This understanding will be helpful in taking care of factors as barriers for ART in PTMCT and as a result reduction the prevalence of AIDS. Outcome of this study will also be useful in understanding the family related issues and will be useful in implementing the family centered approach for ART in PTMCT.

This will definitely be useful in getting family support for the prevention HIV. Most important outcome of this will be production of infant without HIV infection and consequently prevalence of HIV infection will be controlled. This will be definitely useful in the overall improvement in the health of the society and wellbeing of the society (Peltzer et al., 2011; Stinson et al., 2010; Stringer et al., 2010).

Limitations of this include number of participants are less. Study with more number of participants would give more power of analysis. Data obtained in this study will be obtained from the participant women only and there is the possibility of recall bias.  There should be other source of data also to get more robust results.

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