Factors associated with adherence to pMTCT programme in Rwanda

1
Factors associated with adherence to pMTCT
programme in Rwanda

• E. Munyana 1, T. Delvaux 2,
• F.Ndagije 3 , D. Roberfroid 2,
• V. Nizeyimana 1, V. Mugisha 3, R. Sahabo 3, B.
  Elul 4
• 1 TRAC, Rwanda
• 2 ITM, Belgium
• 3 Columbia University, Rwanda
• 4 Columbia University, USA

2
Introduction

• Access to, uptake of and adherence to pMTCT
  services, including HIV testing during pregnancy
  and receipt/ingestion of ARV prophylaxis, remain
  poor in many settings
• Previous studies have suggested a number of
  potential barriers to successful use of pMTCT
  services including
• Negative attitudes towards HIV testing
• HIV-related stigma
• Lack of community involvement
• Poor provider-client interactions
• Poor quality of care in antenatal and obstetric
  services

3
Introduction (2)

• Barriers to access and utilization of the pMTCT
  program in Rwanda have not been systematically
  evaluated
• The Rwandan national pMTCT programme is currently
  shifting from a single-dose Nevirapine (SD-NVP)
  regimen to more complex prophylaxis regimens
• Identifying determinants of adherence to the
  existing SD-NVP regimen can inform the roll-out
  of new regimens
• Adherence to the pMTCT protocol was defined as
  mother-infant pairs ingesting SD-NVP at the
  recommended time

4
Methods

• Both quantitative and qualitative methods used to
  collect data at 14 public-sector pMTCT sites from
  March-May 2006
• SD-NVP pMTCT prophylaxis regimen used at all
  sites at the time of the study
• Quantitative methods Closed-ended interviews
  with 236 HIV-positive women (125 adherent and 111
  non-adherent) in 12 nationally representative
  pMTCT sites selected using multi-stage sampling
  techniques
• Qualitative methods In-depth interviewers with
  34 HIV-positive women and 11 of their partners in
  2 purposively selected pMTCT sites (one urban and
  one rural)

5
Study sites
Quantitative sites Randomly selected stratified
by region (Kigali, north/east and south/west),
geographic area (urban and rural), and
performance (poor and high performance based on
TRAC statistics). Qualitative sites Purposely
selected for feasibility.
6
Recruitment procedures

• Pre-existing patient registers used to identify
  eligible women
• HIV-positive
• gt18 years of age
• Received ANC services at study sites during
  last pregnancy
• Outreach workers contacted eligible women
  and invited them to return to clinic for
  interview
• All women gave written informed consent

7
RESULTS
8
Type of non-adherence to pMTCT prophylaxis
9
Participants characteristics, by adherence status
10
Education, by adherence status

Years of schooling
p0.02
11
Experiences with antenatal care services, by
adherence status
12
Place of delivery, by adherence status
plt0.001
13
HIV testing experiences, by adherence status
14
Disclosure of test results, by adherence status

p0.07
plt0.001
15
Partner testing rates and HIV status, by
adherence status
p0.99
Among women who disclosed their partners status
p0.02
p0.007
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pMTCT prophylaxis experiences, by adherence status
17
Discussed taking pMTCT drugs, by adherence status

plt0.001
plt0.001
18
Receipt of pMTCT prophylaxis before delivery, by
adherence status
plt0.001
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Multivariate analysis

• After adjusting for significant variables in
  bivariate analysis (p0.10), non-adherent women
• Were less educated (more likely to have none or
  up to 3 years of school)
• Made fewer ANC visits (more likely to have lt2
  visits)
• Were much more likely to deliver at home (or not
  at the health facility)
• Were less likely to discuss their test results or
  taking SD-NVP with their partners (if unmarried)
• Were less likely to discuss test results with
  anyone else (besides partner)
• Were more likely to report that their partner was
  HIV negative (discordant couples)
• Were less likely to receive NVP during pregnancy
  and before their expected date of delivery

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Qualitative results

• Interviewees expressed the need for social
  support after receiving HIV results during
  pregnancy
• Elles ont besoin des personnes qui leur rendent
  visite pour leur donner le moral et leur
  conseiller à se calmer face à leur situation.
  Pour moi, cest la première assistance
  nécessaire. 
• ( 32 ans, adhérente)
•  Moi avant, je voulais rester seule, mais
  après, jai intégré lassociation. (..) Dans les
  associations, nous nous connaissons, nous
  causons, on se réconforte. Et après quand tu
  arrives à la maison, tu te sens gaie et contente.
  Mais tu sais que dans les associations, il y a
  des femmes qui vivent avec le VIH il y a 5 ans ?
  Celles - la connaissent beaucoup de choses, quand
  elles te parlent, tu te dis que vraiment la vie
  continue.
• (35 ans, non adhérente)

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Conclusions

• Ensuring adequate number of ANC visits, and
  delivery in a health facility should be
  priorities for the national pMTCT program
• Discussion with partners regarding test results
  and pMTCT prophylaxis should be encouraged
• Distribution of pMTCT prophylaxis upon first
  contact with the health facility should be
  considered, particularly when this occurs late in
  pregnancy
• Linkages with associations and social support
  should also be enhanced

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Thank You