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Health systems, not family factors, most crucial in PMTCT outcomes, Kenyan study shows
Lesley Odendal, 2013-12-17 12:00:00

Women who learn of their HIV infection during pregnancy are at higher risk of vertical transmission of HIV than those who previously knew their status, according to a matched case-control study of Ministry of Health facilities in Nyanza province in Kenya. The study also found that health system factors had a much stronger impact on vertical transmission of HIV than psycho-social factors.

The HIV prevalence of pregnant women is 19.1% in Kenya. Despite a 90% coverage of prevention of mother-to-child (PMTCT) services in Kenya, the rate of vertical transmission is 16% in Kenya. A study which aimed to determine the individual, socio-cultural and health system factors which contribute to PMTCT failure in Kenya, was presented by Maricianah Onono at the International Conference on AIDS and STIs in Africa (ICASA), held in Cape Town, South Africa from 7 to 11 December 2013.

200 participants were enrolled in the case-control study as infants were diagnosed  with HIV from November 2012 to June 2013. 50 cases of HIV-infected mothers of infants aged six weeks to six months with a definitive diagnosis of HIV were enrolled, along with 150 controls of HIV-infected mothers of infants in the same age groups, who were not HIV infected. Cases and controls were matched in a 1:3 ratio based on socio-demographic characteristics and type of health facility.

Vertical transmission of HIV was 2.85 times more likely in mothers who learnt their HIV status during the course of pregnancy (95%CI, 1.40 – 5.77). Women who had not adhered to ART for their own health or for PMTCT were 3.35 times more likely to give birth to an HIV-infected infant (95% CI, 1.48 – 7.58). Infants born through home delivery were 2.40 times more likely to be HIV-infected (95% CI 1.01 – 5.80).

Infants who had not been administered ART for PMTCT consistently in an adherent manner were also 3.92 more likely to be HIV-infected (95% CI, 1.13 – 13.58). In cases where infants were not given ART prophylaxis, even when dispensed at the facility, the infants were 9.71 times more likely to acquire HIV, although the 95% confidence interval for this result is very wide at 2.74 to 34.57.

Facility-related factors which resulted in vertical transmission of HIV to infants included mothers not receiving HIV education (OR=3.57; 95% CI, 1.36 – 9.33); mothers not receiving HIV counselling (OR = 3.35; 95% CI, 1.28 – 12.21); women not being encouraged to involve their male partners (OR = 3.87; 95% CI 1.25 – 11.99); and women not receiving disclosure assistance (OR = 5.63; 95% CI, 1.99 – 15.9).

 Other facility-related factors that increased the risk of HIV transmission to infants were: not being given ART at the first contact in the clinic (OR=2.97; 95% CI, 1.38 – 6.31); health provider not following guidelines for the prescription of ART for mothers (OR = 8.61; 95% CI, 2.83 – 26.15) or for infants (OR = 9.72; 95% CI, 2.75 – 34.37). Factors such as accessibility and cost of health facility services were not significantly associated with vertical HIV transmission.

Psycho-social factors such as disclosure of HIV status to close family members, stigma experienced from the community or facility and intimate partner violence, were not found to be statistically significant factors. However, mothers who lacked any social support were 2.83 times more likely to bear an HIV-infected infant (95% CI, 1.12 – 7.15).

There was no statistically significant difference in the mother’s mean age (26 years), infant’s mean age (3.9 months) and maternal CD4 counts (521 cells/mm3, IQR:354-671 in Cases; 559 cells/mm3, IQR: 361-747) between cases and controls.