Faculty of Health Sciences (ETDs)

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Subject: search.filters.subject.Mother to child transmission

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    Revalence and factors associated with virological nonsuppression amongst HIV positive pregnant and lactating adult women in the Kingdom of Eswatini in 2016-2017
    (2024) Ndlangamandla, Mpumelelo
    Antiretroviral treatment (ART) is the primary intervention for preventing mother to child transmission of HIV service package. The likelihood of vertical transmission of HIV can be drastically reduced by using ART. The World Health Organization (WHO) recommends ART initiation in pregnant and lactating women living with HIV regardless of WHO clinical staging and thereafter to continue combination Antiretroviral Therapy (cART) for life. There are some challenges in implementing the WHO recommendations in settings where many women cannot attend antenatal care services due to social or economic barriers or structural barriers and even fewer women attend postnatal care services. The objectives of this study are to determine the prevalence of virological non-suppression among pregnant and lactating women living with HIV, to quantify the association between self-reported ART use and virological non-suppression and determine socio-demographic, clinical and behavioural characteristics associated with virological non-suppression among pregnant and lactating women living with HIV. This is a cross-sectional study using secondary data from the Swaziland HIV Incidence Survey. The primary study was a population-based survey which was nationally representative, using a cross-sectional study design conducted in 2016-2017 in the Kingdom of Eswatini employing a two-stage stratified cluster sample design. This study sample included adult women living with HIV who were either pregnant or lactating at the time of the survey. Data analysis was conducted using Stata 17. The data analysis made use of sampling weights and clustering of individuals within each enumeration area using weighted clustered logistic regression survey analysis commands in Stata. A total of 195 adult women living with HIV were included in the survey with a median age of 28 years old. Among the women, 104 (54.4%) were either married or cohabiting with someone, and 151 (71.9%) were living in a rural setting. Only 77 (38.8%) had attained primary education as their highest level of education while 122 (63.8%) were lactating. A total of 120 (62%) reported being on ARVs and 158 (81.8%) being virally suppressed. The overall virological non-suppression prevalence of 36.8% was higher than the UNAIDS target of 10% by 2020 to speed up HIV elimination. In a multivariable analysis, two risk factors remained statistically significant. Women who were aged 17 to 24 years old were almost five times more likely to be virologically non-suppressed (aOR=4.7, 95% CI 1.8 - 11.8, p=0.001) while women who did not report ARV use during pregnancy were eight times more likely to have virological non- RESEARCH REPORT (COMH7060) 320775 IV suppression (aOR=8.1, 95% CI 3.0 - 21.8, p<0.001). Maternal age was dichotomised with the younger group compared to the older group (17-24 years, vs 25+ years). An additional analysis excluding self-reported ARV use at pregnancy found that virological non-suppression was associated with maternal age (OR=5.5, 95% CI 2.3 – 13.7, p<0.001) and number of sexual partners in the previous 12 months (OR=7.9, 95% CI 1.6 – 40.5, p=0.013). Maternal age was dichotomised with the younger group compared to the older group (17-24 years, vs 25+ years) The study found that virological non-suppression was associated with maternal age and ARV use at pregnancy. The additional analysis also found a strong association with maternal age and number of sexual partners the women reported having in the previoustwelve months. However, the primary study was not powered to detect differences in virological non-suppression among our population of interest. The sample size was also small, which limited the ability to investigate other possible risk factors. To help the country address the identified gaps, I would recommend the scale up of the DREAMS program and strict following of HIV guidelines to actively monitor viral load and ART uptake during pregnancy and lactation. In addition, messaging around avoidance of multiple sexual partners should be strengthened
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    Exploring healthcare user perspectives on utilisation of prevention of mother to child transmission (PMTCT) services in a high-mobility context in Johannesburg, South Africa
    (2024) Bisnauth, Melanie Ann
    Included in this thesis are four original papers. The first of four papers explored the impact of the Option B+ Prevention of Mother to Child Transmission (PMTCT) of human immunodeficiency virus (HIV) programme on the work of healthcare professionals and, investigated pregnant women living with HIV (WLWH) experiences with antiretroviral therapy (ART) for life, to gain insights in ways to better manage the programme. The first paper (Chapter 6) explored the views of both healthcare providers and user experiences with ART for life at the time the SA’s National Department of Health (NDoH) adopted World Health Organisation (WHO) 2013 guidelines on ARVs for HIV treatment and prevention in 2015. This included changes to PMTCT through Option B+ (now known as lifelong treatment). In 2015, little was known about the impact of these guidelines on the work of healthcare workers (HCWs) and no research at the time had focused on how these changes have affected adherence for the patients. Semistructured interviews were conducted with participants and revealed that work had become difficult to manage for all HCWs because of the need to strengthen indicators for tracking patients to decrease the PMTCT loss to follow-up (LTFU); there was inconsistency in delivery of counselling and support services and a need for communication across clinical departments of the hospital that both offered PMTCT services and had to provide care to the mothers and; a lack of compassion and understanding was existent amongst service providers. The overburdened healthcare environment had affected the overall views and experiences of pregnant WLWH going on ART for life. All patient participants (n=55) responded that they chose the fixed dose combination (FDC) pill for life to protect the health of the baby and felt ART for life could be stopped after giving birth, unaware of the long-term benefits for the mother. Although SA national women were interviewed at the time, RMMCH had provided PMTCT care to many migrants and their experiences needed to be heard. Further research was needed on how to strengthen the programme for long term scalability and sustainability for highly mobile WLWH to better adapt PMTCT programming within the healthcare system. Observations of the population of women accessing PMTCT at RMMCH indicated that many migrant WLWH were utilising the services and called for further investigation and lead into the next two phases of the research study. In addition, Paper 2 (Chapter 7) and Paper 3 (Chapter 8) data collection occurred during the COVID19 pandemic. Paper 2 (Chapter 7) investigated HCWs and their experiences in the provision of PMTCT services to WLWH, specifically migrants that were utilising services during the SARS-CoV-2 (COVID-19) pandemic in SA, to provide further insights on the programme. The COVID-19 pandemic resulted in SA taking preventative and precautionary measures to control the spread of infection, this inevitably proposed challenges to WLWH, especially migrant women by limiting population mobility with border closures and lockdown restrictions. Semi-structured interviews (n=12) conducted with healthcare iii providers across city, provincial, and national levels explored how COVID-19 impacted the healthcare system and affected highly mobile patients’ adherence and utilisation of PMTCT services. Findings revealed; a need for multi-month dispensing (MMD); fear of contracting COVID-19 leading to the disruption in the continuum of care; added stress to the already existent overburdened clinical environment; mistreatment and xenophobic attitudes towards the migrant HIV population and; three key areas for strengthening PMTCT programme sustainability for migrants. Paper 3 (Chapter 8) investigated the insights of migrant WLWH. Migrant typologies were not predetermined a priori. This research allowed for the different mobility typologies of migrant women utilising PMTCT services in a high mobility context of Johannesburg to first surface from the data. By analysing these experiences, it explored further into how belonging to a specific typology may have affected the health care received and their overall experience during the COVID-19 pandemic. Interviews with cross-border migrants (n=22) (individuals who move from one country to another) and internal migrants (n=18) (individuals who transcend borders within a country) revealed that women in cross-border migration patterns compared to interprovincial/intraregional mobility; expressed more fear to utilise services due to xenophobic attitudes from HCWs; were unable to receive ART interrupting adherence due to border closures and; relied on short message service (SMS) reminders to adhere to ART during the pandemic. All 40 women struggled to understand the importance of adherence due to the lack of infrastructure to properly educate them following social distancing protocols. COVID-19 amplified existing challenges for cross-border migrant women to utilise PMTCT services. Future pandemic preparedness should be addressed with differentiated service delivery (DSD) including MMD of ARVs, virtual educational care, and language sensitive information, responsive to the needs of mobile women and to assist in alleviating the burden on the healthcare system. The pandemics’ impact on the study timeline, key lessons learnt and, take away messages when conducting research during this unpredictable time are provided in Chapter 4 (Methods) and Chapter 9 (Discussion). It is important to include these reflections because of the impact it had on all participants and the entire PhD process. Paper 4 will be a future policy piece, drawn from Chapter 9, addressing the need for responsiveness from the SA government and NDoH. Chapter 9 brought together collectively the previous papers 1,2, and 3 and drew overall conclusions, recommendations, and a way forward for both policy and programme implementation. This chapter provided the principal findings of the overall thesis and in relation to other studies in the field, as well as implication for policy practice and research. Chapter 9 concludes with the recommendations for future research on WLWH, mobility typologies, service provision of PMTCT and future pandemic preparedness, and the vision for the South African PMTCT programme.