An exploration of timing of disclosure to male partners by HIV positive women attending a health care centre in Lusaka, Zambia

Magister Public Health - MPHDisclosure of HIV positive status to male partners is well established as a key element in the success of prevention of mother to child transmission of HIV programmes, as it helps improve adherence to ARVs by the women within these programme. However, partner notification rates remain low in the urban areas of Lusaka, Zambia against a high HIV prevalence of 25%. The purpose of this study was to explore the timing of disclosure as part of the process of disclosure amongst women who were part of the PMTCT services at Kaulu health centre in Lusaka. An exploratory descriptive study using qualitative research methods was conducted. 15 women, who were attending the Kaulu health centre PMTCT programme, were requested to participate in a semi-structured interview. The women, who were purposively selected with the aid of the health centre‟s PMTCT focal point nurse, had to have disclosed their HIV positive status to their partner, either before or during the course of their pregnancy or after delivery. To increase rigour, individual interviews were conducted with 5 health workers associated with the PMTCT programme so as to obtain their perspective and experiences on the issue of HIV disclosure amongst their PMTCT patients. Participation in the study was voluntary and all information obtained during the course of the interviews remained confidential and secure. Potential participants were each provided with an explanation of the purpose and process of the study and their informed written consent obtained before the researcher embarked on the interviews. Content analysis of the transcripts was done so as to develop coding categories and identify emerging themes. Disclosure to male partners is an important step in PMTCT and facilitates adherence to HIV care for the family and should be done as early as possible after the woman receives her HIV test result, though there exists a range of alternative times when it can be done. The relationship existing between a couple is very important in determining the timing of when a woman chooses to disclose. PMTCT services need to provide ongoing counselling for HIV positive women during pregnancy and after giving birth that supports, informs and equips them with the necessary skills to make an informed and timely decision about disclosure to a partner. In addition, the PMTCT service providers need to be encouraged to implement couple counselling as a strategy to facilitate disclosure as well as establishment of a peer support network for HIV positive pregnant women. The study findings will be used to contribute to health workers‟ capacity to support women manage the disclosure process to their male partners, thus helping to increase the disclosure rate and also contributing to improving the positive effect of the PMTCT services, in Lusaka, Zambia.South Afric

Universal combination antiretroviral regimens to prevent mother-to-child transmission of HIV in rural Zambia: a two-round cross-sectional study

To evaluate if a pilot programme to prevent mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV) was associated with changes in early childhood survival at the population level in rural Zambia

Non-virologic algorithms for predicting HIV infection among HIV-exposed infants under 12 weeks of age

Early initiation of antiretroviral therapy (ART) has been shown to reduce mortality among perinatally HIV-infected infants, but availability of virologic testing remains limited in many settings

The impact of the Adolescent Girls Empowerment Program (AGEP) on short and long term social, economic, education and fertility outcomes: A cluster randomized controlled trial in Zambia

Background: Adolescent girls in Zambia face risks and vulnerabilities that challenge their healthy development into young women: early marriage and childbearing, sexual and gender-based violence, unintended pregnancy and HIV. The Adolescent Girls Empowerment Program (AGEP) was designed to address these challenges by building girls’ social, health and economic assets in the short term and improving sexual behavior, early marriage, pregnancy and education in the longer term. The two-year intervention included weekly, mentor-led, girls group meetings on health, life skills and financial education. Additional intervention components included a health voucher redeemable for general wellness and reproductive health services and an adolescent-friendly savings account. Methods: A cluster-randomized-controlled trial with longitudinal observations evaluated the impact of AGEP on key indicators immediately and two years after program end. Baseline data were collected from never-married adolescent girls in 120 intervention clusters (3515 girls) and 40 control clusters (1146 girls) and again two and four years later. An intent-to-treat analysis assessed the impact of AGEP on girls’ social, health and economic assets, sexual behaviors, education and fertility outcomes. A treatment-on-the-treated analysis using two-stage, instrumental variables regression was also conducted to assess program impact for those who participated. Results: The intervention had modest, positive impacts on sexual and reproductive health knowledge after two and four years, financial literacy after two years, savings behavior after two and four years, self-efficacy after four years and transactional sex after two and four years. There was no effect of AGEP on the primary education or fertility outcomes, nor on norms regarding gender equity, acceptability of intimate partner violence and HIV knowledge. Conclusions: Although the intervention led to sustained change in a small number of individual outcomes, overall, the intervention did not lead to girls acquiring a comprehensive set of social, health and economic assets, or change their educational and fertility outcomes. It is important to explore additional interventions that may be needed for the most vulnerable girls, particularly those that address household economic conditions. Additional attention should be given to the social and economic environment in which girls are living

Uptake, Outcomes, and Costs of Antenatal, Well-Baby, and Prevention of Mother-to-Child Transmission of HIV Services under Routine Care Conditions in Zambia

<div><p>Background</p><p>Zambia adopted Option A for prevention of mother-to-child transmission of HIV (PMTCT) in 2010 and announced a move to Option B+ in 2013. We evaluated the uptake, outcomes, and costs of antenatal, well-baby, and PMTCT services under routine care conditions in Zambia after the adoption of Option A.</p><p>Methods</p><p>We enrolled 99 HIV-infected/HIV-exposed (index) mother/baby pairs with a first antenatal visit in April-September 2011 at four study sites and 99 HIV-uninfected/HIV-unexposed (comparison) mother/baby pairs matched on site, gestational age, and calendar month at first visit. Data on patient outcomes and resources utilized from the first antenatal visit through six months postpartum were extracted from site registers. Costs in 2011 USD were estimated from the provider’s perspective.</p><p>Results</p><p>Index mothers presented for antenatal care at a mean 23.6 weeks gestation; 55% were considered to have initiated triple-drug antiretroviral therapy (ART) based on information recorded in site registers. Six months postpartum, 62% of index and 30% of comparison mother/baby pairs were retained in care; 67% of index babies retained had an unknown HIV status. Comparison and index mother/baby pairs utilized fewer resources than under fully guideline-concordant care; index babies utilized more well-baby resources than comparison babies. The average cost per comparison pair retained in care six months postpartum was $52 for antenatal and well-baby services. The average cost per index pair retained was$88 for antenatal, well-baby, and PMTCT services and increased to $185 when costs of triple-drug ART services were included.</p><p>Conclusions</p><p>HIV-infected mothers present to care late in pregnancy and many are lost to follow up by six months postpartum. HIV-exposed babies are more likely to remain in care and receive non-HIV, well-baby care than HIV-unexposed babies. Improving retention in care, guideline concordance, and moving to Option B+ will result in increased service delivery costs in the short term.</p></div

Quantity of resources utilized and unit costs for the provision of PMTCT services from the first antenatal visit through six months after delivery.

<p>3TC: lamivudine; ARV: antiretroviral; AZT: zidovudine; DNA: deoxyribonucleic acid; HIV: human immunodeficiency virus; NVP: nevirapine; PCR: polymerase chain reaction; PMTCT: prevention of mother-to-child transmission; USD: United States dollar.</p>a<p>A mother was considered to have initiated triple-drug ART if site registers indicated that she had either a CD4≤350 cells/µL or an ART referral indicated in the site registers.</p>b<p>Differences in means between mothers considered to have initiated triple-drug ART and not considered to have initiated triple-drug ART were calculated using an independent two-sided t-test.</p>c<p>Zambian national guidelines recommend co-trimoxazole 400 mg/80 mg tablets twice daily from 14 weeks gestation for all HIV-infected pregnant women <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0072444#pone.0072444-Government1" target="_blank">[5]</a>. The guidelines also recommend ARV prophylaxis for HIV-infected pregnant women not yet on triple-drug ART, including: AZT 300 mg tablets twice daily from 14 weeks gestation through one week postpartum, one NVP 200 mg tablet at delivery, and 3TC 150 mg tablets twice daily from delivery through one week postpartum <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0072444#pone.0072444-Government1" target="_blank">[5]</a>.</p>d<p>Zambian national guidelines recommend co-trimoxazole prophylaxis for HIV-exposed babies from six weeks of age until HIV infection is excluded, with a recommended dose of 2.5 ml of 240 mg/5 ml co-trimoxazole suspension per day for babies less than six months of age <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0072444#pone.0072444-Government1" target="_blank">[5]</a>. The guidelines also recommend daily NVP from birth through one week after the cessation of breastfeeding for infants born to mothers not yet on triple-drug ART and daily NVP from birth through six weeks of age for infants born to mothers on triple-drug ART, with a recommended dose of 1–1.5 ml of 10 mg/ml NVP suspension per day from birth to six weeks and 2 ml per day from six weeks to six months of age <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0072444#pone.0072444-Government1" target="_blank">[5]</a>. The guidelines also recommend that HIV-exposed infants receive a first HIV DNA PCR test at 6 weeks of age and a second HIV DNA PCR test at six months of age if the first HIV DNA PCR test was negative <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0072444#pone.0072444-Government1" target="_blank">[5]</a>.</p

Average cost per mother/baby pair for actual antenatal, well-baby, and PMTCT services received and estimated triple-drug ART services received from the first antenatal visit through six months after delivery.

<p>ART: antiretroviral therapy; CI: confidence interval; PMTCT: prevention of mother-to-child transmission; USD: United States dollar.</p>a<p>A mother was considered to have initiated triple-drug ART if site registers indicated that she had either a CD4≤350 cells/µL or an ART referral indicated in the site registers.</p>b<p>Differences in means between index and comparison mother-baby pairs were calculated using an independent two-sided t-test.</p>c<p>Antenatal service costs include the costs of fixed resources and provider time per clinic visit, diagnostics, vaccines, and non-ARV drugs provided to both index and comparison mothers.</p>d<p>Well-baby service costs include the costs of fixed resources and provider time per clinic visit, vaccines, and non-ARV drugs provided to both index and comparison babies.</p>e<p>PMTCT service costs include the costs of ARV prophylaxis for index mothers not yet on triple-drug ART, ARV prophylaxis for babies, co-trimoxazole prophylaxis for index mothers and babies, and HIV DNA PCR tests for index babies.</p>f<p>Triple-drug ART service costs include the costs of pre-ART and on-ART services, including costs of fixed resources, provider time for clinic visits, ARV drugs, non-ARV drugs, and diagnostics, for index mothers considered to have initiated triple-drug ART. See <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0072444#pone.0072444.s001" target="_blank">Appendix S1</a> for details on the estimate of triple-drug ART service costs.</p

Quantity of resources utilized and unit costs for the provision of antenatal and well-baby services from the first antenatal visit through six months after delivery.

<p>BCG: Bacille Calmette Guerin; DPT-HepB-Hib: diphtheria, pertussis, tetanus, hepatitis B, haemophilus influenza type b; HIV: human immunodeficiency virus; USD: United States dollar.</p>a<p>Differences in means were calculated using an independent two-sided t-test.</p>b<p>Mean time from the first antenatal visit to delivery for mother/baby pairs retained in care through delivery and mean time from first antenatal visit to last antenatal visit for mother/baby pairs not retained in care through delivery.</p>c<p>Zambian national guidelines recommend the following for a pregnant woman presenting to care with a gestational age of 24 weeks: four outpatient clinic visits; one hemoglobin test and one urine dipstick test at the first antenatal visit; one hemoglobin test at a subsequent antenatal visit for HIV-infected women; two rapid plasma reagin tests, one at the first visit and one three months later; one rapid HIV test at the first antenatal visit with a second, confirmatory rapid HIV test if the first rapid HIV test is positive or with repeat rapid HIV tests every three months during pregnancy and while breastfeeding if the first rapid HIV test is negative; two doses of tetanus toxoid vaccine four weeks apart for pregnant women who have not been previously vaccinated and one dose of tetanus toxoid vaccine for pregnant women who have been previously vaccinated and who have received less than five previous doses in total; daily supplements (30 tablets per month) of ferrous sulfate 200 mg tablets and folic acid 5 mg tablets; three doses (nine tablets) of sulfadoxine 500 mg/pyramethamine 25 mg for HIV-uninfected pregnant women; four tablets of mebendazole 500 mg, one at each antenatal visit; and one 2.4 MU dose of benzathine penicillin for women with a positive rapid plasma reagin test <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0072444#pone.0072444-Government1" target="_blank">[5]</a>.</p>d<p>Small quantities of the following resources were utilized by mothers in our sample during the postnatal period rather than the antenatal period: first rapid HIV tests (3 tests in total), ferrous sulfate 200 mg (120 tablets), folic acid 5 mg (104 tablets), and sulfadoxine 500 mg/pyramethamine 25 mg (6 tablets). This resource utilization is included in the average resource utilization figures in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0072444#pone-0072444-t003" target="_blank">Table 3</a>.</p>e<p>Mean time from delivery to the last well-baby visit within six months after delivery. Patients with no visits after delivery had zero months of postnatal follow up.</p>f<p>Zambian national guidelines recommend the following care for babies during the first six months after delivery: seven outpatient clinic visits; one dose of the BCG vaccine at birth (with a repeat dose at 12 weeks of age if the infant does not have a scar); four doses of the OPV vaccine at birth, six weeks, 10 weeks, and 14 weeks; three doses of DPT-HepB-Hib at six weeks, 10 weeks, and 14 weeks; and a one-time vitamin A supplement of 100,000 IU (half of a 200,000 IU Vitamin A gel cap) at six months <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0072444#pone.0072444-Government1" target="_blank">[5]</a>.</p>g<p>The cost per outpatient clinic visit of $4.01 is for the urban district hospital and includes$2.46 per visit for provider time and $1.55 per visit for fixed resources. In the primary analysis, the unit cost for the urban district hospital was applied to outpatient visits at all four study sites. The cost per outpatient clinic visit, including the cost of fixed resources and provider time, was$2.42 at the peri-urban health center, $4.45 at the rural mission health center, and$2.56 at the rural health center.</p