1. BARRIERS TO AND FACILITATORS FOR RETENTION OF MOTHER BABY-PAIRS IN CARE IN ELIMINATION OF MOTHER TO CHILD TRANSMISSION OF HIV IN EASTERN UGANDA Gerald Obai Makerere University college of Health Sciences School of public Health 9 th May 2014 Venus

2. Presentation outline  Introduction  Study Objectives  Study findings  Implications for the study findings  Discussion points  Sharing of experiences in retention of mother-baby pairs

3. Introduction and background  In 2012, there were 210,000 new HIV infections in children through mother to child transmission, Globally (UNAIDS, 2009)  About 600 new infections daily, 90% in sub-Saharan Africa  Vertical transmission occurs during pregnancy, delivery and breastfeeding  Accounts for 95% of HIV infections in children

4.  About 7/100 pregnant women are HIV positive (MoH, 2010)  An estimated 149,661 children below the age of 15 were living with HIV in 2009 (UAC, 2012).  About 20% of these HIV infected children acquired the infection through MTCT (UAC, 2012).  When there is no intervention, 2/10 exposed children are infected after birth

5.  A lot has been done to reduce transmission during antenatal and perinatal periods  Period between 0-24 months has remained problematic  Mainly due to LTFU, reported at 53%  This poses a challenge in efforts to reduce MTCT of HIV to <5% by 2015 as called for by UNAIDS

6.  To overcome this challenge of low retention, strategies to improve retention at each stage of the care cascade must be addressed  This will ensure HIV free survival of the babies while also keeping their mothers alive

7. Objective  To determine the barriers to retention of mother baby pairs in care  To determine the facilitators for retention of mother- baby pairs in care in eMTCT of HIV in Eastern Uganda  To determine possible solutions for improved retention of mother baby pairs in care

8. Methods and approaches  This was a prospective cross sectional study  Study was carried out in Manafwa and Tororo districts in Eastern Uganda  Respondents were HIV positive mothers with babies less than 2 years of age  Informed consent was obtained from the mothers before data collection

9. Findings from the study  A total of 41 mothers were interviewed  26/41 (63.4%) of mothers had missed at least 1 appointment  36/41 (87.8%) of the babies had been tested for HIV  17/36 (47.2%) of the babies were tested within the first 2 months

10.  20/24 (83.3%) of the mothers who missed appointments said their spouses were aware that they were on ARVs  More mothers 15/26 (57.7) who missed appointment had attained primary level of education as compared to those who had attained secondary education

14. Implication of the findings  6/10 mothers/baby miss an appointment by the 18 th month  This increases the risk of infection as well as LTFU  Nearly 90% of the children tested for HIV  Less than 50% of the infants had the first PCR done within two months of birth

15.  We should aim at 100% testing within the first 2 months  Infants infected during pregnancy, delivery or early postpartum often die before they are recognized as having HIV infection  Testing of infants for HIV at 6 weeks, or soon thereafter helps to guide clinical decision-making at the earliest possible stage

16.  HIV disease progression is rapid in children  Without early treatment almost 50% of children die before their 2 nd birthday  Should be put on treatment as early as possible

17.  Level of education attained has influence on retention into care  Mothers with secondary level of education are more likely to retain into care than mothers with primary level of education  Should counselors consider mother’s education during counseling?

18.  The following were the main reasons for missing appointment  Forgetting appointment date  Social factors like marriage ceremonies  Lack of privacy during counseling  Lack of transport money  Fear of disclosure

19.  Monthly appointments pose challenges with regards to remembering the dates  Giving priority to other social events over personal/baby’s health means we have to do more during counseling

20.  Strive to give a little more time during counseling  Studies done in South Africa and Malawi showed that counselors generally spend less than five minutes with the mothers (Coutsoudis, 1999)  As a result, most mothers do not recall the information given to them during counseling

21.  Lack of privacy during counseling is a challenge to retention of mother baby pairs in care  Lack of adequate space for counseling compromises on privacy and confidentiality which may result in LTFU  Stigma and discrimination is still a big challenge to retention of mother-baby pairs in care (Kalembo and Zgambo, 2012)

22.  In a country where stigma is still high, the prospect of one’s HIV status being involuntarily revealed to others is undesirable  Privacy during counseling should be maintained so that we do not only have mother-baby pairs LTFU, but also ensure the mothers concentrate during the counseling session

23. Main reasons for retaining in care  Simple things routine done help retain mother-baby pairs in care  Should stress the importance of weight taking, counseling on infant feeding, and possibility of HIV free baby

24. Conclusion and recommendations  Retention of mother baby pairs can be achieved through:  Addressing issues which make mothers to miss their appointments  Implementing key suggestions by mothers for improved retention

25. Acknowledgement  Africa Hub for funding this dissemination workshop  URC ASSIST project for providing the funding for the study.  District health officers and health facility in-charges for giving us permission to carry out the study  The health workers who helped us in data collection  Mothers who accepted to participate in this study

26. THANK YOU FOR LISTENING TO ME

27. Discussion points  Why are more mother-baby pairs with spouse disclosure missing appointments?  What are the best strategies to ensure mothers remember the appointment dates?

28. Share experiences on strategies used to retain mother-baby pairs in care

29. Way Forward