PMTCT Uptake in Botswana
PMTCT was introduced in Botswana in 199 and the program has been widely availed in health facilities all the country. Due to the fact that a majority of pregnant women seek maternal care services in public facilities, the government incorporated routine HIV testing as an element of antenatal care (Government of Botswana, 2008). He overall objective of the programme is to improve child survival and development by reducing HIV transmission from mother to child. The program has four major components which include; preventing pregnancy among young girls, preventing unwanted pregnancy among HIV-positive women, ARV prophylaxis to prevent mother to child HIV transmission, and the provision of support for the mother and her family (Kweneng District Council, 2011; Government of Botswana, 2008). Through the years, the PMTCT programme has evidenced a fair of achievements and challenges alike.
On achievements according to the government, the programme has had major achievements in the access of the programme, testing of expectant mothers, take-up pf HIV prophylaxis and treatment by HIV-positive mother, and the proportion of new-borns tested by day 42 (Government of Botswana, 2008). Other achievements for the program include successful integration of PMTCT into sexual reproductive health services, increased PMTCT testing uptake to 98% in 2010 from 49% in 2002, adoption of routine HIV testing, early infant testing rollout, increased PMTCT (AZT/HAART) uptake to 93% in 2010 from 27% in 2002.
PMTCT guidelines in Botswana emphasize on the importance of HAART for all HIV positive expectant women (Ministry of Health, 2008). The defined adult criteria indicate that pregnant women who initially test negative when registering for antenatal care, they should be retested at the 36th week or when labour sets in, so as to detect intercurrent infection during the term. HIV positive pregnant women who are not yet on HAART are expected to have CD4 count and clinical screening as a priority and it should be expedited. Further on, the guidelines dictate that all pregnant women eligible for HAART should be started without exception. In no circumstance that HART should be deferred till the second semenster even if the woman’s immune status is poor. During labour, all women who are on HAART should be administered with high dose AZT and not sd-NVP. Those women not eligible for HAART should be put on short-course AZT 300mg BD as from the 28th week (Ministry of Health, 2008).
Factors Affecting Uptake of ART in PMTCT
The WHO identifies Botswana as one of the 22 priority countries that require PMTCT services (UNICEF, 2016). It is recommended that with effective scaling up of PMTCT in Botswana and the other countries can prevent over 250,000 new infections each year (World Health Organization (WHO), 2013). Whereas Botswana’s PMTCT has evidenced significant achievement, it is also plagued by challenges and barriers which hamper the uptake. Botswana’s PMTCT programme faces a number of challenges which include weak infant follow-up, testing and initiation on HAART, suboptimal access to HAART among all eligible patients, male involvement and participation, inadequate implementation of routine and rapid HIV testing, and inadequate implementation of Infant and Young Child Feeding (IYCF) counselling (Keapoletswe, 2010).
Knowledge and individual beliefs – There is an established link between knowledge of HIV and PMTCT and the uptake of PMTCT services. Studies in Botswana (Creek, et al., 2009) and Togo (Boateng, Kwapong, & Agyei-Baffour, 2013) are some examples that demonstrate this link. The studies show mixed responses on factors such as HIV testing, and acceptability of PMTCT. Poor knowledge of HIV transmission and ARV drugs has also been highlighted in several studies as one of the reasons for dropping out of PMTCT programmes (Peltzer, Mlambo, Phaswana-Mafuya, & Ladzani, 2010; Kiarie, Kreiss, Richardson, & John-Stewart, 2003). Pregnant mothers may also harbour doubts about the efficacy of ART in MTCT (Kiarie, Kreiss, Richardson, & John-Stewart, 2003; Duff, Rubaale, & Kipp, 2012), or have beliefs that ARVs can cause HIV (Towle & Lende, 2008), or ARVs causes harm to the unborn child (Stinson & Myer, 2012).
Cultural beliefs and gender dynamics – In most of Botswana, the traditional gender roles and cultural beliefs are sustained. Typically, men are the one who make decisions that determine the woman's participation in HIV testing and the corresponding uptake of PMTCT services (Avert, 2016). Just like in most African communities, in Botswana, pregnancy is viewed as ‘a woman’s affair’ and the man’s primary role is to provide financial support. Men rarely accompany their women to antenatal clinics for PMTCT services due to the stereotype. A man accompanying his wife to the antenatal clinic often evokes negative attitude from community members as reported in the case of Uganda (Byamugisha, Tumwine, Semiyaga, & Tyllesk?r, 2010).
Marital status – Marital status has a mixed impact on the uptake of PMTCT. Whereas some studies report that a married marital status negatively influences the uptake of PMTCT services (Muyoti, 2007), other studies show that unmarried HIV positive expectant mothers do not access PMTCT services and acquire ARV drugs as much as married women do (Gourlay, et al., 2015). The relationship between marital status and the uptake of PMTCT among Botswana mothers is yet to be clearly established.
The level of education – Women with a high level of education have demonstrated more positive attitudes towards PMTCT uptake compared to their counterparts (Muyoti, 2007). Drawing on Botswana’s education profile, the characteristics of PMTCT seeking behaviour can be drawn.
Area – Women in rural areas are generally disadvantaged in ARV uptake (Gourlay, et al., 2015). Accessing PMTCT services including ART drugs is a particular challenge to pregnant women in rural parts of African countries. this may be attributed to distance, time and cost of travel to access health services (Gourlay, et al., 2013).
Psychological factors – A review of literature reveals that there are psychological barriers that affect the initiation and adherence to PMTCT services. Some studies have reported that women describe depression, shock or denial upon learning about their status during antenatal visits (Painter, et al., 2004; Stinson & Myer, 2012), they also express fears about their condition and death (Nkonki, Doherty, Hill, Schaay, & Kendall, 2007; Duff, Kipp, Wild, Rubaale, & Okech-Ojony, 2010), and are also concerned about handling the side effects and the lifelong treatment. The desire to regain health and protect the health of the unborn child are facilitating factors to initiating and continuing with ART (Theilgaard, et al., 2011; Stinson & Myer, 2012).
Disease progression – pregnant women tend to seek PMTCT services depending on the presentation of the disease. Studies have revealed that pregnant women suffering from the disease but lack the symptoms do not feel the need for ARVs for PMTCT (Levy, 2009; Theilgaard, et al., 2011).
Personal management and supply of treatment – Some patients may lose or sell the tablets, while other may forget to take them or may run out. This may affect the adherence of pregnant women to ARV (Mepham, Zondi, Mbuyazi, Mkhwanazi, & Newell, 2011; Kiarie, Kreiss, Richardson, & John-Stewart, 2003). There are also issues pertaining to tolerability (e.g. vomiting) (Laher, et al., 2012).
Partners – Some women fear disclosing their status to their partners and family members. Non-disclosure to partners has been associated with not attending HIV clinics for ART, and not ingesting ARVs (Gourlay, Birdthistle, Mburu, Iorpenda, & Wringe, 2013). Lack of partner support is a hindrance whereas support serves as a facilitating factor (Awiti, et al., 2011)
The type of ARV regimen that one takes during pregnancy also influences adherence. For instance, according to a study in Kenya, women taking NVP are more likely to adhere when compared to those taking twice-daily AZT (Kiarie, Kreiss, Richardson, & John-Stewart, 2003). Also, women on cART are more likely to adhere compared to those on NVP alone (Stringer, et al., 2010). It is also hypothesised that the increasing complexity and duration of drug regimens may be having a negative effect on access to ARVS, and subsequent adherence.
Factors related to patient-health care provider
The interactions between the patient and staff may also have an impact on ART-seeking behaviours. Most women have cited negative staff attitudes as a barrier to revisit the facilities (Winestone, et al., 2012; O'Gorman, Nyirenda, & Theobald, 2010; Varga & Brookes, 2008), and this limits the opportunity to receive ART. Fear of confidentiality breach may also serve as a hindrance factor. Notably, in most African settings, patient-staff interaction, young HIV positive pregnant mothers have expressed facing discrimination during these interactions (Gourlay A., et al., 2014). Overall, some patient does experience difficulties with clinical staff or procedures and this has a negative impact on ART uptake.
Factors Related to Health Care System
Botswana’s health system is also characterised with factors that may hinder the uptake of ART for PMTCT. A number of studies (Duff, Kipp, Wild, Rubaale, & Okech-Ojony, 2010; Painter, et al., 2004; Theilgaard, et al., 2011) have revealed that one of the major barriers to PMTCT ART uptake is the shortage of trained clinic staff. Those available are overwhelmed by the high patient volume and this contributes to extended waiting periods, staff stress, staff misunderstandings, poor quality counselling sessions, and staff fails.
Another factor related to the health care system is the shortage of resources (including ARVs) (Sprague, Chersich, & Black, 2011; Doherty, Chopra, Nsibande, & Mngoma, 2009), poor integration of services, referrals and tracking systems (Winestone, et al., 2012), and poor record keeping (Sprague, Chersich, & Black, 2011).
Accessibility of services is another important factor affecting access to PMTCT among pregnant women. The distance to facilities and the frequency of visits required is a particular challenge especially for those in rural areas (O'Gorman, Nyirenda, & Theobald, 2010). In addition, the costs (perceived or real) of maternity services and treatment are also a concern among many women, especially in light of the low economic status. Late presentation to antenatal clinics is also a barrier to accessing ART.
Factors to Improve
- Improve decentralisation of PMTCT services to more rural areas
- Maintain regular supplies of HIV test kits and drugs
- Prioritise testing and enrolment for symptomatic women regardless of the symptomatic state.
- Promote male involvement
- Improve knowledge, attitudes, and practices regarding ART uptake and general PMTCT among women of childbearing age. Women should be educated on the benefits of ANC/PMTCT services and the corresponding adherence.
- Improve efforts to address HIV stigma, discrimination, and PMTCT. HIV stigmatisation and overall stereotyping hampers PMTCT-seeking behaviours.
- Fundamental health system issues such as accessibility, staffing, partner support, confidentiality, and disclosure also need addressing.
- Botswana can also benefit from strengthening health systems to enhance counselling and partner/community support in order to improve uptake.
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