Loss to Follow-Up among HIV Positive Pregnant and Lactating Mothers on Lifelong Antiretroviral Therapy for PMTCT in Rural Uganda

Abstract

Background. Mother-to-Child Transmission of HIV accounts for more than 90% of all pediatric HIV infections. However, Prevention of Mother-to-Child Transmission (PMTCT) of HIV through provision of lifelong ART to HIV positive mothers faces various challenges which affect its success. One of such challenges is the loss to follow-up (LTFU) of mothers. Methodology. We conducted a cross-sectional study utilizing both quantitative and qualitative data collection methods. We were able to trace 279 HIV positive, pregnant, and lactating mothers among mothers who were initiated on lifelong ART for PMTCT in public health facilities in Ntungamo district, Western Uganda. The proportion of those who were lost to follow-up was determined, and Log binomial regression with stepwise backward elimination method was employed to identify factors associated with LTFU. Focus group discussions (FDGs) of women on lifelong ART and key informant interviews (KIIs) of peer educators were also performed. Results. Out of the 279 mothers that were successfully traced and interviewed, 103 (37%) were identified as lost to follow-up. The prevalence of LTFU was higher among those whose transport costs were above $2.75, adj (adjusted) PR (Prevalence Ratio) 1.6 (95% CI; 1.02-2.55); those who waited beyond one hour before being attended to, adj PR 1.74 (95% CI; 1.02-2.96); and those who assumed that their infant was already infected, adj PR 1.76 (95% CI; 1.15-2.70). On interviews, LTFU in these mothers was attributed to fear of swallowing antiretroviral drugs, HIV related stigma and discrimination, inadequate facilitation of the peer educators, long patient waiting time, and transportation to the health facilities. Conclusion. More than one-third of mothers initiated on lifelong ART for PMTCT in Ntungamo district were lost to follow-up over a period of 25 months. Recommendations. Provision of regular and adequate pre-ART and ART adherence counseling and provision of routine health education would reduce LTFU.

Incidence and Predictors of Loss-to-follow-up Among Pregnant and Breastfeeding Women on Option B+ PMTCT Program in Northwest Ethiopia: a Retrospective Follow-up Study.

“…Among these measures, increasing trained human power including midwives, frequent follow-up schedule and better drug preparation ( xed dose ART treatment) by giving better consideration for mothers to implement the program effectively (40). The current study nding is also lower than studies conducted in different African countries such as Uganda (15,16,18), South Africa(24), Malawi (14,46) and Kenya (19).This discrepancy might be due to the difference in study time, operational de nition of the outcome variable, and characteristic of study participants. For example, the study period for a study conducted in Malawi was 3-years record review (14) whereas the current study incorporated recent years' data which had better improvement ART coverage.…”

“…Supportive ndings were reported from previous studies in Ethiopia and Brazil (10,30,48). Possible explanations for this might be remote area mothers are forced to travel long distances in order to get the nearest hospital, which necessarily involves high costs which leads LTFU (16) and cannot easily get transport services due to poor /lack of road construction, makes women to walk long distances by bare foot, this leads them less likely to adhere to option B+ strategy (31) and resulting in missing the appointments (15,32). This justi cation is also supported by the report given that lack of access to health care service leads to poor adherence and LTFU to option B+ PMTCT drugs (15).…”

“…Reports from Africa indicated that, maternal age less than 25 years (12,13,15,21,26,27,32), less than 26 years (33), and less than 30 (23) were statistically signi cant positive predictor for LTFU. Moreover, Educational status (15,28), Marital status (19), unemployment status (34), number of pregnancies (13), religious reasons, and partner HIV status (12,16) were a signi cant predictor for LTFU. In addition, studies showed that the baseline low CD4 cell counts and high viral load measurement were positively associated with LTFU among women in PMTCT services (36,37).…”

“…Another retrospective cohort study in Myanmar showed that pregnant women's LTFU rate was 7 per 1000 person-years under option B+ PMTCT programs (11). A retrospective follow-up study in different African countries showed that the incidence of LTFU among pregnant and lactating mothers under option B+ program were still high which ranges from 16% to 53.7 (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26). Previous studies in Ethiopia showed that the rate of LTFU among women under Option B+ program varied region to region.…”

Outcomes of HIV Exposed Infants and Predictors of Positivity after Option B+ Guideline Implementation in Amhara Regional State’s Referral Hospitals, Ethiopia

“…Monitoring adherence and retention for mothers on Option B+ were a big challenge and information had shown that there was substantial LTFU in Uganda (33). A transport costs above $2.75, waiting time greater than 1 hour, and perception that the child is already infected were associated with loss to follow-up, but mothers knowledge that ARV drugs work was protective for LTFU (34).…”