Date Published: March 31, 2018
Publisher: BioMed Central
Author(s): Tamara Nsubuga-Nyombi, Simon Sensalire, Esther Karamagi, Judith Aloyo, John Byabagambi, Mirwais Rahimzai, Linda Kisaakye Nabitaka, Jacqueline Calnan.
As part of efforts to improve the prevention of mother-to-child transmission in Northern Uganda, we explored reasons for poor viral suppression among 122 pregnant and lactating women who were in care, received viral load tests, but had not achieved viral suppression and had more than 1000 copies/mL. Understanding the patient factors associated with low viral suppression was of interest to the Ministry of Health to guide the development of tools and interventions to achieve viral suppression for pregnant and lactating women newly initiating on ART as well as those on ART with unsuppressed viral load.
A facility-based cross-sectional and mixed methods study design was used, with retrospective medical record review. We assessed 122 HIV-positive mothers with known low viral suppression across 31 health facilities in Northern Uganda. Adjusted odds ratios were used to determine the covariates of adherence among HIV positive mothers using logistic regression. A study among health care providers shed further light on predictors of low viral suppression and a history of low early retention. This study was part of a larger national evaluation of the performance of integrated care services for mothers.
Adherence defined as taking antiretroviral medications correctly everyday was low at 67.2%. The covariates of low adherence are: taking other medications in addition to ART, missed appointments in the past 6 months, experienced violence in the past 6 months, and faces obstacles to treatment. Mothers who were experiencing each of these covariates were less likely to adhere to treatment. These covariates were triangulated with perspectives of health providers as covariates of low adherence and included: long distances to health facility, missed appointments, running out of pills, sharing antiretroviral drugs, violence, and social lifestyles such as multiple sexual partners coupled with non-disclosure to partners. Inadequate counseling, stigma, and lack of client identity are the frontline factors accounting for the early loss of mothers from care.
Adherence of 67% was low for reliable viral suppression and accounts for the low viral suppression among HIV-positive mothers studied, in absence of any other factors. This study provided insights into the covariates for low adherence to ART and low viral load suppression; these covariates included taking other medications in addition to ART, missed appointments in the past 6 months, feels like giving up, doesn’t have someone with whom to share private concerns, experienced violence in the past 6 months, and faces obstacles to treatment and confirmed by health providers. To improve adherence, we recommend use of a screening tool to identify mothers with any of these covariates so that more intensive adherence support can be provided to these mothers.
Human immunodeficiency virus (HIV) causes a chronic infection that leads to a progressive disease. Without treatment, most persons with HIV develop acquired immunodeficiency syndrome (AIDS) within 10 years of infection, which results in HIV transmission to sex partners, substantial morbidity, and eventually death . Testing identifies infected persons and is the entry point to a continuum of HIV health care and social services that improve health outcomes, including survival. This continuum includes diagnosis (HIV testing), linkage to and retention in continuous medical care for HIV, prevention counseling and other services that reduce transmission, and consistent antiretroviral therapy (ART) for viral suppression .
This study collected data on different variables from HIV-positive mothers with known low viral suppression only, since looking at these characteristics in all HIV-positive women would bias results; given that their characteristics may not be similar or have the same distribution in the women with good viral suppression.
Adherence of 67.2% among mothers with low viral suppression in this study is very low. The main covariates were distance to travel to health facility leading to missed appointments and running out of drugs, sharing antiretroviral drugs, drug side effects, lack of pre-ART counseling, gender-based violence, social lifestyles such as multiple sexual partners, non-disclosure to partners, and stigma and discrimination. Qualitative findings from providers corroborated these findings. To improve the quality of care provided to mothers, the information from this study can be used to screen pregnant women and lactating mothers on ART for any of the factors strongly associated with low adherence to ART (and thus low viral load suppression) and then provide support through intensive adherence counselling and self-management or peer-to-peer support.