F ACTORS THAT HINDER THE SUCCESS OF THE PREVENTION OF

MOTHER TO CHILD TRANSMISSION (PMTCT) OF HIV/AIDS IN PUBLIC

HOSPITALS. (ACASE STUDY OF KENYATTA NATIONAL HOSPITAL)

NAME: LUCY KAMAU

REG NO: C01/21235/2009

A RESEARCH PROPOSAL SUBMITTED IN PARTIAL FULFILMENT

OF THE REQUIREMENT FOR THE AWARD OF A DEGREE OF

BACHELOR OF ARTS (COUNSELLING PSYCHOLOGY) UNIVERSITY OF

NAIROBI

NOVEMBER, 2011

DECLARATION

This Project Proposal is my original effort and has not been

submitted for any degree or diploma in any University or institution

other than the University of Nairobi.

Name _____________________________

Signature ___________________________

Date _____________________________

This Project Proposal has been submitted with my approval as

university supervisor.

Name _____________________________

Signature ___________________________

Date _____________________________

DEDICATION

This research project is dedicated to all HIV positive pregnant

mothers who made its completion possible by availing the necessary

information to me and who have an uphill task in trying to rise

above the stigma meted against them by their environments.

ACKNOWLEDGEMENT

I wish to acknowledge in a very special way everybody who in one

way or another supported and assisted me in gathering all the

information contained in this research paper and its preparation.

My sincere gratitude goes to the entire team of department of

psychology and especially my lecturers for endowing me with

knowledge and skills which guided me in carrying out this research,

in the compiling of the data collected and hence the production this

report.

Am particularly grateful to my supervisor, Mrs. J. Wachira, who

tirelessly helped me to edit this paper by giving adequate and

relevant advice on how to produce a report that is of acceptable

standard.

I am deeply indebted to the Head of the Department of Psychology,

Prof P Kariuki for the great support and encouragement that I have

received from her throughout this course.

Utmost, I pledge all my allegiance to the Almighty God without Whose

presence this course would not have been possible.

TABLE OF CONTENTS

Declaration..............................................ii

Dedication..............................................iii

Acknowledgement..........................................iv

Table of Contents.........................................v

List of Tables.........................................viii

Abbreviations /Acronyms...................................x

Abstract................................................ xi

CHAPTER ONE...............................................1

1.1Introduction...........................................1

1.2Back ground of the problem……………………………..................2

1.2.1Profile of Kenyatta National Hospital……………………………..4

1.3Statement of the Problem ……………………………………………………………4

1.4Purpose of the Study:………………………………….....................5

1.4.1.................General Objectives

………………………………………………….5

1.4.2...................Specific Objectives……………………... 5

1.5Research

Hypothesis..........................................................

........................................6

1.6Research questions_……………………………………......................6

1.7Significance of the study………………….......................6

1.7.1 The stakeholders in the Health Management........6

1.7.2 The Management ………………………………………………………………6

1.7.3 The Patients …………………………………………………………………….7

1.7.4 Researchers ……………………………………………………………………7

1.8 Limitation of the study ……………………………………………………………….7

1.8.1 Accessibility ………………………………………………………………….7

1.8.2 Respondents…………………………………………………………………..7

1.9 Scope of the Study ………………………………………………………………………7

CHAPTER TWO : LITERATURE REVIEW..........................8

2.1Introduction...........................................8

2.2 Theoretical Review.....................................9

2.2.1...................................Personal Factors9

2.2.2..............Social Cultural and Religious Factors16

2.3 Reducing barriers to PMTCT Services...................19

CHAPTER THREE : RESEARCH DESIGN AND METHODOLOGY..........24

3.1Introduction..........................................24

3.2 Research design.......................................24

3.3 Research Instrumentations.............................24

3.3.1.....................................Questionnaires24

3.3.2.........................................Interviews25

3.4 Target population.................................... 25

3.5 Sample design....................................... 25

3.6 Data collection procedures.............................. 26

3.7 Timeline............................................ 27

3.8 Data Analysis....................................... 27

CHAPTER FOUR : DATA ANALYSIS PRESENTATION AND

INTERPRETATION.......…………….. 28

4.1Introduction........……………………...28

4.2 Demographic information ............................. 28

4.2.1....................Gender of the responder is..... 28

4.2.2. Age of the Respondent ........................ 29

4.2.3......................The respondents’ Marital status

29

4.2.4 Education level of the respondents........... 30

4.3 Personal Factors. ………………...30

4.3.1........Antenatal Clinics Attended since Conception30

4.3.2. Knowledge of HIV Status before visiting the Clinic31

4. 3. Nature of the testing process………………………………………………………..32

4.3.6 Knowledge about HIV/AIDS and its transmission………………………………………….

32

4.3.7 Services provided upon the affirmation of your HIV status

………………………………… 33

4.3.8 Clinic environment …………………………………………………………………………. 33

4.4.1 Community behavior towards a HIV positive person

………………………………………. 33

4.4.2 Reaction of partner/spouse upon realizing one is HIV positive

…………………………….. 33

4.4.3 Public Disclosure about the Respondents HIV status

………………………………………. 34

4.4 5 Beliefs in the Community associated with the HIV disease

………………………………… 35

4.5 Dissemination of Information on prevention of mother to child

transmission of HIV by the Service Providers

…………………………………………………………………………………..36

4.5.1 Availability of private rooms for counselling

………………………………………..36

4.5.2 Confidentiality of the test results

…………………………………………………….37

4.5.3 Means of communications put in place to relay information

on prevention of mother to child transmission of HIV/ AIDs

…………………………………………………………...37

CHAPTER FIVE: DISCUSSION, CONCLUSION AND RECOMMENDATION

….............. 39

5.1 Introduction ……………………………………………………………………………………….39

5.2 Summary of the findings…………………………………………………………………………39

5.3 Conclusion……..…………………………………………………………………………………40

5.4 Recommendations ………………………………………………………………………………. 40

References …………………………………………………………………………………………….41

Appendix I: Questionnaire ……………………………………………………………………………44

LIST OF TABLES

Table 3.1 Population size ………………………………………………………… 25

Table 3.2 Sample population………………………………………………………. 26

Table 4.1 Reaction of the partner/spouse upon realizing one is HIV

positive…….. 33

LIST OF FIGURES

Figure 4.1 Gender …………………………………………………………………………………. 28

Figure 4.2 Age bracket …………………………………………………………………………… 29

Figure 4.3 Marital status ……………………………………………………………………………29

Figure 4.4: Shows education level of the respondents

……………………………………………. 30

Figure 4.5 Number of antenatal clinics attended

………………………………………………….. 30

Figure 4.6 Knowledge of HIV status before visiting the clinic

…………………………………... 31

Figure 4.7 Nature of the testing process …………………………………………………………..

32

Figure 4.8: Shows knowledge about HIV/AIDS and its transmission

…………………………….. 32

Figure 4.9 Public Disclosure about the Respondents HIV status

…………………………………. 34

Figure 4.10 Beliefs in the Community Associated with the HIV

disease…………………………. 35

Figure 4.11 Availability of private rooms for counseling

………………………………………….36

Figure 4.12 Confidentiality of the test result ………………………………………………………

37

Figure 4.13 Counseling HIV positive pregnant mothers in relationship

to the unborn babies …… .38

ABBREVIATIONS /ACRONYMS

AIDS Acquired Immunodeficiency Syndrome

ANC Antenatal Clinic.

ANTENATAL Before birth

CCC Comprehensive Care Centre

FP Family planning

GBV Gender Based Violence

HAART Highly Active Antiretroviral Therapy.

HIV Human immune virus.

KDHS Kenya Demographic Health Survey.

KNH Kenyatta National Hospital.

KPA Kenya Pharmaceutical Association

MCH Maternal Child Health.

MOH Ministry of Health.

MTCT Mother to Child Transmission

NACC National Aids Control Council.

NVP Nevirapine

PMTCT Prevention of Mother to Child Transmission.

POSTNATAL After birth

RH Reproductive Health

STI Sexually Transmitted Infections

UNAIDS United Nation against Acquired Immunodeficiency

Syndrome.

UNGASS United Nations General Assembly Special Session

UNICEF United Nations on Integration of Child Education

Fund.

VCT Voluntary Counseling and Testing.

WHO World Health Organization.

PLHIV People living with HIV

ABSTRACT

The purpose of this study was to determine the factors that

hinder the success of prevention of mother to child transmission of

HIV in public hospitals.

Mother to Child Transmission (MTCT) is by far the largest

source of HIV infection in children under the age of 15years.The

main components of the prevention of mother to child transmission of

HIV (PMTCT) intervention package have included community awareness,

voluntary counseling and testing (VCT), prevention of HIV positive

women becoming pregnant, use of antiretroviral drugs (mono/dual

prophylaxis of Highly Active Antiretroviral Therapy (HAART), and

either replacement or exclusive breast feeding.

In Kenya many of these strategies have been implemented since

2002 as part of the National HIV/AIDS prevention strategy. The

objective of this study was to identify the personal and community

factors that hinder the success of PMTCT services in public

hospitals. The other objective was to find out ways that can be used

to enhance dissemination of information on prevention of mother to

child transmission of HIV/AIDS. To meet the objectives of the study

a descriptive research design using survey method to administer

questionnaires was chosen. The research was a case study of Kenyatta

National Hospital, (KNH). Literature review was conducted through

web and manual searches reviewing past records of journals,

magazines and other PMTCT management data bases. The data was

collected using a well-structured pre-tested questionnaire.

Stratified random sampling was used so as to obtain the sample

population. Analysis of the data was done by the researcher after

editing, coding and organizing into charts percentages and tables.

This facilitated data interpretation drawing of conclusions as well

is making appropriate recommendations.

The study found out that majority of the respondents attended two

antenatal clinics, HIV testing was unfriendly and they have little

knowledge about HIV transmission. The study found out that various

services provided by the health care givers upon the affirmation of

the respondents HIV status are extremely dissatisfying and the

clinic environment was rated largely as extremely dissatisfying due

to poor ventilation, uncleanliness and the unattractiveness of the

service providers. The study found out that majority of the

respondents feel that the community is unfriendly towards a HIV

positive person and the disease is regarded as one that infects

prostitutes. There is a lot of stigma associated with the HIV

disease both in the community and in health care institutions.

Spousal hostility was expressed by the majority of the respondents

and most HIV positive pregnant mothers preferred their results kept

as secret. The largest mode of communication for relaying

information on mother to child transmission of HIV and methods of

prevention is print materials such as wall charts and brochures. The

government considers it important to keep as confidential the HIV

status of an individual and information given by the patients is

also confidential. This is the reason why counseling is done in

private rooms.

Following are the recommendations of the study:

Firstly the policy makers should critically analyze the indicated

causes of failure of prevention of mother to child transmission of

HIV (PMTCT) in public hospitals with a view to addressing them.

Secondly, clear and practical standard operating procedure (SOP) to

be drafted that can be adhered to by public hospitals pertaining to

prevention of mother to child transmission of HIV.

Thirdly public awareness campaigns should be carried out to

sensitize the masses on mother to child transmission of HIV and how

this transmission can be avoided before conception, during

pregnancy, and at birth.

CHAPTER ONE

1.1 Introduction.

Mother to child transmission (MTCT) of Human Immunodeficiency Vims

(HIV) is responsible for more than 90% of HIV infections in children

under 15 years according to United Nations against Acquired

Immunodeficiency Syndrome, (UNAIDS:2001).An estimated 50000 to 60000

infants get the HIV infection annually in Kenya through their

mothers, AIDS in Kenya( 2005).A study carried out by Ongech (2007)

in Kenya in Nairobi county found out that 35%- 40% of babies are

infected with HIV by their mothers during pregnancy, delivery or

through breastfeeding .

Kenya’s HIV population report (2000) indicated that there are

greater challenges to prevention of mother to child transmission

(PMTCT) management in public hospitals that have constrained

facilities. Kenyatta National Hospital, being one of the major

referral hospitals in East and Central Africa has the mandate to

contain disease outbreaks more so prevention of neonatal HIV

infection. Despite the major strides made to control HIV/AIDS and

the existence of feasible and affordable interventions to reduce the

rate of mother to child transmission(MTCT) by 50% ,the HIV pandemic

still has a solid grip in Kenya and threatens to reverse the gains

made in key health measures and in many sectors of the economy. Of

concern is the gradual rise in infant mortality rate in Kenya

attributed to the HIV infection from 64/1000 live births in 1993 to

77/1000 live births in 2)03,(MOH, June 2006)

According to the Ministry of Health (MOH:2005),out of the 4172 women

who tested positive, 2208 of them and 1,341 HIV positive babies

received Start Dose Nevirapine 13DNVP). Kenya designed programs to

prevent the spread of HIV and AIDS, to care for those with HIV/AIDS

and most susceptible ones like unborn children. The Kenya

Demographic Health Survey (KDHS) puts child mortality (children

under five years) at |I 5 deaths out of 1000 (115/1000), this

translates to 1 death in every 9 children born before their fifth

birthday,(KDHS 2003).In Kenya, the National AIDS Control Council

carried out a study on HIV prevalence in Dec 2006 and found out that

there was a decline from 7% reported in the Kenya demographic and

health survey of 2003 to 5.1%.Despite this decline ,the current

estimates indicate 10% of the reported AIDS cases are in children

under five years of age. The main route of HIV infection for the

infants and children is through vertical transmission (MTCT) while

in adult it is through sexual intercourse. (KDHS 2003).

1.2 Back ground of the problem.

Kenya is home to one of the world’s harshest HIV and AIDS epidemics.

An estimated 1.5 million people are living with HIV; around 1.2

million children have been orphaned by AIDS; and in 2009, 80,000

people died from AIDS related illnesses. Many people in Kenya are

still not being reached with HIV prevention and treatment services.

Only 1 in 3 children needing treatment are receiving it. This

demonstrates that Kenya still has a long way to go in providing

universal access to HIV treatment, prevention and care.

The declaration of commitment on HIV/AIDS of the United Nations

General Assembly Special Session (UNGASS, 2001) on HIV prevention

among infants and young children, committed to reduce the proportion

of infants infected with HIV to 505 by 2005 and 205 I by the year

2010 by ensuring that 80% of the pregnant women access Prevention of

Mother to Child (PMTCT) services. Through effective prevention, new

HIV infections in children under the age of 15 are becoming

increasingly rare in many parts of the world. In 2003, reported

estimates of new HIV infections were less than 1000 children in

North America and Western Europe and less than 100 in Australia and

New Zealand, conversely, this is not the case in sub-Saharan Africa,

where 90% of the cases among children have occurred. For example, in

Malawi approximately 83,000 children were infected at the end of

2003. Moreover, the estimated national HIV prevalence among -

pregnant women was 20%, Green, (2005)

Most children infected with HIV acquire it through mother-to-child

transmission (MTCT), which can occur during pregnancy (15-20%),

labor and delivery (50%), or during breastfeeding (33%).In the

absence of any intervention, the risk of MTCT of HIV 15-30% in non-

breastfeeding populations. Breastfeeding by an infected mother

Increases the risk by 5-20% to a total of 20-45 %,( Nduati:

2005).Throughout the world,

Antenatal care is the main entry point for preventing children from

becoming infected. However, HIV-related stigmatization has

insidiously continued to undermine prevention of mother-to-child

transmission (PMTCT) efforts.

According to Bollinger and Stower (2009), HIV-related stigmatization

is both a social phenomenon and a process that results in a powerful

and discrediting social label. This label radically and negatively

changes the way individuals are viewed and treated by others

(enacted stigma), and how they view themselves (self-stigma). For

pregnant women who consider disclosing, it often elicits fears of

abandonment, ostracism, domestic violence or being blamed (felt

stigma). Studies have shown that such women tend to opt out of being

tested (if tested, they rarely disclose), opt out of PMTCT programs,

do not complete the scheduled visits, or do not abruptly cease

breastfeeding as -recommended by the program.

A report in one of the World Health Organization (WHO) bulletin

rightly said, “the Climate goal of public health programs for the

prevention of mother -to-child Transmission (PMTCT) is to save lives

of large numbers of children born to HIV- infected mothers” (Newell

M: 2001).At the recent regional consultation on accelerating

prevention of Mother-to-Child Transmission (PMTCT) and pediatric

care and treatment, governments of nine countries with high HIV

prevalence were urged to take immediate action to expand and

strengthen existing PMTCT services, as well as to increase Treatment

to infected mothers and children, United Nations on Integration of

Child Education Fund( UNICEF2009).The HIV and AIDS epidemic

continues to have a devastating impact on children and women in this

region, contributing to increased deaths of both children and

mothers as well as creating more orphans, UNICEF Regional Sid visor

on HIV and AIDS Alnwick(2009).

1.2.1 Profile of Kenyatta National Hospital.

Kenyatta National Hospital is the oldest hospital in Kenya. It was

founded in 1901 with a bed capacity of 40 as the Native Civil

Hospital. The institution was renamed the King George VI Hospital in

1952.At that time the settler communities were served by the nearby

European Hospital (now Nairobi Hospital).It was renamed Kenyatta

National Hospital after Jomo Kenyatta the first president of Kenya,

following independence from the British. It is currently the largest

referral and teaching hospital not only in the country but also in

East and Central Africa. Kenyatta national Hospital has a capacity

of 1800 beds and has over 6000 staff members. It covers an area of

45.7 hectares. The University of Nairobi medical school and several

government agencies are located within its premises.

1.3 Statement of the Problem

The Kenya Demographic Health Survey (KDHS 2003) puts child mortality

(children under five years) at one death in every nine children born

before their fifth birthday. The main route of transmission of the

HIV to the child is vertical from the mother to the child either in

pregnancy, during labor and delivery or through the mother’s breast

milk. According to United Nations General Assembly Special Session

UNGASS (2005), pediatric AIDS remains a largely uncontrolled

epidemic despite the availability of proven interventions for the

prevention of mother to child HIV transmission (PMTCT) and

substantial donor investments for implementing the intervention

programs.

The Ministry of Health in Kenya, (MOH 2006), indicates that inspite

of the major strides made to control the spread of HIV/AIDS, and the

existence of feasible and affordable

intervention to reduce the rate of transmission from mother to child

(MTCT) by 50%, the HIV pandemic still has a solid grip and threatens

to reverse the gains made in key health measures and in many sectors

of the Kenyan economy. The Ministry of Health (MOH 2006) report

continues to indicate that the gradual rise in infant mortality rate

in Kenya is due to the increase in HIV transmission from mother to

child (MTCT).

According to the UNICEF Regional Advisor on HIV and AIDS, Alwick

(2009), the HIV/AIDS epidemic continues to have a devastating impact

on children and mothers as well as creating more orphans. Current

estimates according to this report indicate that 10% of the reported

AIDS cases are in children less than five years of age.

It was against this background that the researcher examined the

personal and the community factors that hinder the success of

prevention of mother to child HIV transmission. The researcher also

sought to find out ways that can be used to enhance the

dissemination of information on the prevention of mother to child

transmission of HIV infection in public hospitals in Kenya in order

to reduce child mortality due to HIV and AIDS.

This was a case study of Kenyatta National Hospital.

1.4 Purpose of the Study:

The purpose of this study was to examine the personal and community

factors that hinder the success of the services of prevention of

mother to child transmission of human immune virus. It also sought

to find out ways that can be used to enhance the dissemination of

information on prevention of mother to child transmission of HIV

infection.

1.4.1 General Objective.

To investigate the factors that hinder the success of Prevention of

Mother to Child Transmission (PMTCT) services in public hospitals.

1.4.2 Specific Objectives.

1) To find out the personal factors that hinder the success of

Prevention of Mother to Child Transmission (PMTCT) services in

public hospitals.

1 To identify community factors that hinder the success of PMTCT

services in public hospitals (social cultural and religious

factors).

3) To find out ways that can be used to enhance dissemination of

information on Prevention of Mother to Child Transmission of HIV.

1.5 Research Hypothesis

The success of prevention of mother to child transmission of

HIV in public hospitals will greatly reduce the spread of the

epidemic in the entire country.

1.6 Research question.

1) What are the personal factors that hinder the success of

Prevention of Mother to Child Transmission (PMTCT) services

in public hospitals?

2) How do community factors (social cultural and religious)

hinder the success of PMTCT in public hospitals?

3) How does the Prevention of Mother to Child Transmission

(PMTCT) process hinder the health care providers from

succeeding in providing PMTCT services in public hospitals?

1.7 Significance of the study.

A detailed study into the factors that hinder the success of

PMTCT services in public hospitals will benefit the following

among others:

1.7.1 The stakeholders in Health Management

The study was to be useful to the Health Sector as it was to

determine factors that hinder the success of Prevention of

Mother to Child Transmission and give suggestions on how to

improve service delivery in provision of PMTCT in Healthcare.

The government would use the study to improve on its many

health institutions in the country which have not been using

the laid down procedures in ensuring availability of essential

services in PMTCT in hospitals.

1.7.2 The management

The study was also to be useful to the management team

comprising pharmacists, Doctors, Nurses, and Clinicians who

would use this to review the Prevention of Mother to Child

Transmission setbacks and improve on their service delivery.

The team would likely use the study to identify the optimum

staffing capacity that they should maintain md still be

profitable and have delighted clients.

1.7.3 The patients

The study was also to benefit the patients who are likely

to get more informed staff and enjoy quicker and friendlier

services. It would also encourage more patients to continue

visiting hospitals as they would be sure of getting the

services necessary in the Prevention of Mother to Child

Transmission (PMTCT) of HIV infection.

1.7.4 Researchers

This study was expected to be useful to other researchers

who would further research in various aspects that are

affecting health management organizations across the world.

1.8 Limitation of the study.

The following were the limitations:

1.8.1 Accessibility

It was difficult to reach the facility on time given the huge

traffic jam that piles up in the evening after work and the

high cost of travelling by public means which brought forth

many hassles in my pursuit of the study.

1.8.2 Respondents

Being that a section of my respondents were professionals with

tight schedules made it intricate to meet them at my own time

implying that I had to be make several phone calls to book

them for an opportunity for interview.

1.9 Scope of the Study.

The scope of this study was conducted at Kenyatta National

Hospital in Maternal Child Health and Antenatal care (MCH,

ANC) and the respective wards within the hospital. The concern

was the Doctors, Nurses and Clinical officers that comprise

therapeutic management committee and the antenatal and

postnatal mothers who were attending the clinic or had been

admitted in the wards. The research study was carried out

within a period of 3 months.

CHAPTER TWO

LITERATURE REVIEW

2.1 Introduction.

Despite the availability of proven interventions for the

prevention of mother-to-child HIV transmission (PMTCT) and

substantial donor investments for implementing them in

developing countries, pediatric AIDS remains a largely

uncontrolled epidemic. The majority of cases occur in sub-

Saharan Africa, where high HIV prevalence among pregnant women

combines with an under-resourced health-care infrastructure to

produce nearly 90% of the world’s 800 000 children who are

believed to be infected each year, UNAIDS, (2009).Several

ambitious goals for pediatric AIDS control were set up by

various international bodies in the provision of PMTCT

services to 80% of those in need by 2010, (United Nations

General Assembly Special session on HIV/AIDS).

While these goals are clearly appropriate in their scope, the

disparity in which outcomes they actually target reveals a

lack of clarity and consensus around how to monitor the

effectiveness of PMTCT programmes. Without this clarity, it is

difficult for policy makers in developing countries to mount a

coordinated response. Most infant HIV infections could be

averted. The problem is that very few of the world's pregnant

women are being reached by prevention of mother-to-child

transmission (PMTCT) services. This study looked at why the

situation is so dire, and what might be done to improve

matters. The most effective way to prevent mother-to-child

transmission of HIV involves a long course of antiretroviral

drugs and avoidance of breastfeeding, which reduces the risk

to below 2 %,( Ngacha: 2006). In high-income countries, the

number of infant infections has plummeted since this option

became available in the mid-1990s.

2.2 Theoretical Review.

2.2.1 Personal Factors

According to World Health Organization (WHO 2009) around

400,000 children aged less than 15 years became infected with

HIV in sub Saharan Africa. Almost all of these infections

occurred in low and middle income countries, developing

countries and more than 90% are the result of mother-to-child

transmission during pregnancy, labour and delivery, or

breastfeeding. Without interventions, there is a 20-45% chance

that a baby born to an HIV-infected mother will also turn

positive. Since 1999, it has been known that much simpler,

inexpensive courses of drugs can also cut mother-to-child

transmission rates by at least a half. The most basic of these

comprises just two doses of a drug called Nevirapine - one

given to the mother during labour and the other given to her

baby soon after birth. These short-course treatments, combined

with safer infant feeding, have the potential to save many

tens of thousands of children from HIV infection each year,

recommended by Kenya Pharmaceutical Association (KPA: 2008).

Recognizing this potential, the member states of the United

Nations set targets for preventing mother-to-child

transmission (PMTCT) in 2001, as part of a landmark agreement

called the United Nations General Assembly Special Session

(UNGASS) declaration. Preventing mother-to-child transmission

(PMTCT) might seem simple: just hand out lots of pills. In

fact there is much more to it than that. To begin with, the

vast majorities of women in the low and middle-income

countries have never been tested for HIV and do not know

whether they are infected. This means that effective PMTCT

programmes must provide counseling and testing services to

determine which women need assistance. And even if a clinic

offers counseling and testing to every pregnant woman, the

reality is that not all of them accept. Others, having been

tested, fail to return to receive their results. This is just

the beginning of a series of steps that leads to the ideal

outcome, which is to reduce the risk of transmission as far as

possible. At each step, some women drop out. By the end, it's

possible that only a minority will remain. Of more than half a

million women who attended clinics in twelve countries, only

71% received I counseling; of those who were counseled, only

70% took an HIV test; among women who tested HIV positive,

only 49% received preventive drugs. Assuming that HIV

prevalence among all women was similar to the rate among those

who were tested, fewer than one in four HIV-infected women who

attended a clinic went on to receive the drugs that they

needed, UNICEF (2002).

Low educational level and lack of accurate information about

HIV/AIDS among women of child bearing age is a contributing

factor to low numbers seeking PMTCT services. On non-adherence

to treatment instructions, some women remain in denial about

their pregnancy and therefore do not appreciate the importance

of ante natal clinics (ANC).These women end up in the health

facility at the last moment when it is too late to start any

HIV prevention strategy (Babakia: 2005).In a study carried out

in USA among women of childbearing age, just over one and half

had the correct knowledge of effective prenatal HIV prevention

strategies .The study also noted that even among the pregnant

who should have received the knowledge through

counseling ,only 65% knew of the existence of PMTCT and ARV

prophylaxis (Anderson 2004).According to the Kenya Demographic

Health Survey (KDHS 2003), knowledge and awareness of HIV and

AIDS is nearly universal among women in Kenya except among

those with no education. The same survey indicates that

illiteracy among females is 21% compared to the males with

12%.The Kenya Demographic Health Survey (KDHS) and the

Behavior Surveillance Survey (BBS) 2003, found out that over

70% of respondents of age group 15-49 years, had basic

information on prevention and transmission of HIV, but less

than one third (l/3) of them had knowledge of the specific

action that mothers could take to prevent HIV in pregnancy.

Personal influences have been a major hindrance and some

of the main issues are: accessibility; clinic resources;

testing methods; fear and distrust; disclosure and

discrimination; drug effectiveness; treatment for mothers;

feasibility of replacement feeding; and male visits to

antenatal clinics. Poor women in low and middle-income

countries have many responsibilities. Besides caring for their

children they are expected to work hard preparing food,

fetching water or tending crops. Many live a long way from

their nearest health facility and have little access to

transport. It is therefore hardly surprising that a third of

the world's pregnant women do not attend antenatal clinics,

(Bollinger and Stower: 2002). Many other women visit clinics

only once during pregnancy and nearly two-thirds give birth

unattended by a skilled health worker. This already greatly

reduces the number that can be reached by prevention of mother

to child transmissions (PMTCT) programmes. The problem is

compounded if women have to make follow-up visits to receive

counseling, drugs or other services (Wamalwa: 2006). In

Zambia, Lusaka clinic, it was found that a third of those

given the drug never ingested it totally thus putting the

mothers and the unborn babies at risk (Katarina 2005).

To increase attendance, clinics should aim at being as

accessible as possible. Improvements might include providing

travel services or changing clinic operational hours. In rural

India, the government boosted attendance by setting up a

Saturday clinic. Women who are HIV positive should be

encouraged to give birth at a clinic. Nevertheless, to attain

high coverage, PMTCT programmes also need to reach those who

deliver at home. One way to achieve this is to give single

dose Nevirapine pill to each HIV-positive woman in advance -

perhaps even at the time of diagnosis - to be kept at home and

taken at the start of labour (Ong’ech: 2006). Yet although

giving the drug in advance can increase the number of women

who receive it, there is no guarantee that every pill will be

swallowed. One study in Zambia found that a third of those

given the drug never ingested it. Scientists in Uganda found

better results, but only among a community used to taking part

in scientific research.

Moreover, to be fully effective, medication needs to reach

newborn babies as well as their mothers. Infant doses are

given in syrup form and are usually available only to women

who give birth in clinics. Some programmes like those in

Kenyatta National Hospital Comprehensive Care Centre (KNH CCC)

have however succeeded in dispensing the syrup in advance,

inside sealed oral syringes, so that it can be given after

home births. This has made it easier for the mothers to give

the initial dose to the neonate immediately at home; the

pharmacists also give measuring syringes to the mothers for

accurate measurement of the dose at home.

As in the majority of rural Kenya, PMTCT programmes can

increase acceptance of self- administered drugs by working

with traditional birth attendants, who attend the majority of

home deliveries. With sufficient training, traditional

midwives might also be able to provide other services such as

HIV education, testing and counseling, and advice on infant

feeding. The conventional form of HIV testing in antenatal

clinics is called VCT - Voluntary Counseling and Testing.

According to the VCT approach, women are offered a HIV test

but many women worry that they will be stigmatized for

accepting the test. An alternative model is routine testing,

whereby women are told that HIV testing is a standard part of

antenatal care, but they can opt out if they want to. Removing

the special status that is often given to HIV testing helps to

make PMTCT services more acceptable, (KDHS: 2006).

Numerous studies have found that switching from VCT to routine

testing can dramatically improve take-up of testing in PMTCT

programmes. According to Nduati 2005), in one hospital in

rural Uganda, the proportion of pregnant women with documented

HIV status at discharge more than doubled from 39% to 88%

after routine testing was introduced. When Botswana changed

its testing procedure nationwide in 2004, it immediately

increased testing rates from 75% to 90% (Opot: 2004).The

process can be made even more efficient if the basic

information given before testing is addressed ID small groups

instead of individuals. One-to-one counseling on personal

issues can then follow as required. According to Opot (2004),

despite the benefits of routine testing, it does not address

the issue of women not returning to receive their results.

This is why some programmes have introduced rapid testing.

Unlike conventional HIV tests, which days or even weeks, rapid

tests can produce a result in as little as twenty minutes

usually means that many more women learn about their HIV

status. However, it also s that women have less time to

prepare themselves for the result.

Prevention of Mother to Child Transmission (PMTCT)

interventions can still be effective third trimester, during

labour and even after delivery. Programmes should therefore

every opportunity to offer testing to women of unknown HIV

status. They should consider retesting women who were

previously negative, in case they have since become infected.

According to Lull et al (2006), a study of eight hundred

pregnant women in Botswana showed an estimated 2% of pregnant

women who had previously taken part in routine testing for HIV

and were found to have a negative status developed -LY later

in pregnancy or during postpartum. Therefore women with acute

HIV infection and those who became infected after routine

testing were missed. Using these results, Lull et al (2006)

estimated that 43% of mother to child transmissions in

Botswana may be cue to undetected HIV infection late in

pregnancy and postpartum. By integrating HIV counseling and

testing into all parts of the maternal and child health system

- including family planning clinics, labour and delivery

services, postpartum care and even immunization clinics, PMTCT

programmes can reach significantly more women, some women

refuse HIV testing because they are afraid of learning that

they have a life threatening disease - afraid that the

resulting worry and stress will quicken death, as observed by

Mary Akinyi attending Medicine San frontiers (MSF) clinic in

Kibera has this to say, “I would like to know my status if

this will prevent my baby from getting infected, but on the

other hand I fear knowing that I am among the dead and I am to

experience much suffering of AIDS, so I would not want to know

my HIV status for fear of those deep thoughts (Nduati. 2005).

Others refuse because they perceive few benefits of testing,

either to their unborn babies (due to poor counseling,

distrust or misunderstandings) or to themselves (if they are

unlikely to receive long-term treatment). The effects of PMTCT

interventions are invisible, and they are based on medical

concepts that are alien to traditional cultures. As health

worker Macharia Kamau explains: "Labour is already a stressful

environment. You are pregnant, poor, vulnerable, marginalized,

and uneducated. At that point, what do you rely on? What your

mother told you when you left home? Your cultural beliefs - or

this stranger who’s standing there saying, ’Take this

pill?’"(Ongech: 2007).

One study in Cote d’Ivoire found that a significant number of

pregnant women who had been diagnosed with HIV were unwilling

to take part in follow-up visits because they had had bad

experiences when dealing with health workers. Problems

included distrust of the staff and their medicines,

dissatisfaction with counseling, disbelief of test results,

and fear of hostile staff. To allay concerns, clinic staff

should try to be approachable and supportive, while programmes

should seek to raise community awareness of PMTCT services and

their benefits. Such promotion may take the form of videos,

talks, brochures, radio programmes or songs. Working with

community leaders - perhaps by setting up advisory boards -

promotes the idea of collective ownership, and can help to

raise acceptance of PMTCT services which will also encourage

many pregnant mothers to go to the clinics as in the case of

Mbagathi District Hospital and KNH where pregnant women are

educated with the aid of videos and session talks and such

other activities as songs and dances.

Recent studies by the consortium of NGO’s (2009), against

infant mortality, found out that many women are concerned

that, if found to be HIV positive, their diagnosis will not

remain secret: this was observed in Uganda. "You see the woman

who wants to test has to go from the waiting room where all

women gather and enter the nurse's office. After Testing she

goes out of the nurse's office in full view of the other women

who will read on her face that she tested for HIV and begin

rumours",(Masete2006).HIV-related stigma and discrimination

are found in all societies and can lead to social isolation

and even loss :f family support. Fear of such prejudice can

cause some women to refuse HIV testing, or not to return for

their test results. Often the greatest worry is the reaction

of a male partner.

An infant does not only need to be born HIV negative; it needs

food and shelter, something that the mother may depend on her

spouse to provide. For a mother to have ad of her status

without consulting her partner is risky. To talk with him is

difficult to tell her partner that she is HIV positive is

risky. Further, to know she is HIV positive is risky. She will

be frightened about her own fate. Against these risks, she

balances s a new intervention with as yet no visible impact.

In this tragic calculus, noting a test to tell their partners.

Most are afraid of violence or abandonment. In many societies

it is common for men to blame their partners for being

infected, even if they too have HIV. Disclosure to health

workers and midwives can be hindered by concerns about

confidentiality .A HIV positive, pregnant woman who has not

disclosed her diagnosis to her partner, family or friends is

generally less likely to accept preventive drugs and to

practice unconventional methods of infant feeding, for fear of

revealing that she is infected. Prevention of Mother to Child

Transmission (PMTCT) programmes should therefore seek to make

disclosure less difficult for their clients, for example by

running support groups or anti-stigma campaigns. They might

also try to identify and assist those who wish to avoid or

defer disclosure.

One good idea is to involve male partners in the Prevention of

Mother to Child Transmission (PMTCT) programmes. If couples

are counseled and tested together then there is less potential

for blame and recrimination. Counsellors can emphasize the

man's responsibility for protecting the health of his partner

and family, and can promote the use of PMTCT and other

services, resulting in much higher take-up rates. Possible

ways to increase male participation include hand delivered

invitations and routine testing for men who accompany their

partners according to National Aids Control Council (NACC:

2010).Unfortunately, it is usually far from easy to persuade

men to attend what they regard as women's clinics dealing with

women's issues. Disclosure to health workers and midwives is

also very important, especially at the time of delivery, but

can be hindered by concerns about confidentiality. A less

common worry is that health workers or traditional birth

attendants might refuse to help someone whom they know to be

infected. This scenario is observed in Uganda. According to

Jane (2008) women of child bearing age in South West Uganda

echoed this: “We are delivered by our local midwives, who do

not have gloves, so if you tell them that you are sick, that

you have the virus, she may refuse to attend... so you don't

tell them at all". Possible improvements include better

training of health workers and midwives, and clinic layouts

designed to ensure privacy.

2.2.2 Social Cultural and Religious Factors

According to Kiarie (2009), community factors (socio-cultural)

remain a major challenge in the fight against HIV/AIDS

pandemic in Sub Saharan Africa. The factors majorly include

stigma and discrimination, gender violence, HIV testing,

knowledge of prevention of mother to child transmission

(PMTCT) techniques and male partner participation. Kiarie

(2009) notes that the potential of PMTCT to serve as the entry

point for family-based HIV care can only be realized if there

is wide utilization of antenatal care (ANC) services,

availability of PMTCT services, and widespread uptake of

voluntary counseling and testing (VCT) during pregnancy. In

some settings, low uptake of some or all of these services

remains a major limitation to scaling up care linkages.

While the utilization rate of health-care facilities during

pregnancy may be relatively high in many countries, there are

large variations between countries and within the same

countries. For example, a study in a rural community in South

Africa found that 44% of women delivered their babies at home,

mostly without assistance from a traditional birth attendant.

In a district of Rajasthan state, India, 71.4% of pregnant

women in urban areas and 36.1% in rural areas received more

than three antenatal care services. In Fez, Morocco, 77% of

women had some form of antenatal care. Without antenatal care,

women cannot benefit from HIV diagnosis or any of the

prevention of mother to child (PMTCT) and treatment

interventions available to them or their families. According

to Banda and Msungu (2008) factors influencing a woman’s

decision whether to deliver in a health-care facility included

proximity to the facility, transportation costs, education and

marital status. Although women in the South African study were

aware of the risk of mother-to-child HIV transmission, only 9%

of the pregnant women surveyed had ever been tested for HIV.

Accessibility of antenatal care and prevention of mother to

child transmission (PMTCT) services in Sub-Saharan Africa

varies greatly across and within countries (e.g. urban versus

rural areas), depending on economic, geographic, cultural, and

social characteristics. An evaluation of UN-supported

prevention of mother to child transmission (PMTCT) pilot

projects (2003) in 11 countries (Botswana, Burundi, Cote

d’Ivoire, Honduras, India, Kenya, Rwanda, Tanzania, Uganda,

Zambia, and Zimbabwe) found that among women who came to

health centers for antenatal care, uptake of HIV counseling

and testing ranged from 25% to more than 90%. However, only

64% to 83% of women who accepted an HIV test returned to

collect their results. According to United Nations General

Assembly Special Session(UNGASS:2007),factors associated with

acceptance of HIV testing among pregnant women attending

antenatal clinics include education level, knowledge of mother

to child transmission (MTCT) and HIV testing, and partner

participation or perception that the clinic offers privacy and

that social support from relatives and peers is available.

According to Kenya Demographic Health Survey (2008), in

addition to factors specifically affecting uptake of antenatal

care, there have also been reports suggesting a need for

improvements in the quality, frequency, and duration of HIV

counseling. Although some studies have found that

discrimination in the community toward HIV positive women may

not be a major limitation, it remains clear that stigma and

discrimination, lack of male partner support, and negative

attitudes of health workers toward pregnant women are still

significant barriers to women’s participation in PMTCT

programs, as observed in a program in Gaborone, Botswana,

despite women being offered free access to ARVs and formula

feeding.

Low acceptance of Voluntary Counseling and Testing (VCT) among

pregnant women remains a major rate-limiting step in the

uptake of prevention of mother to child transmission (PMTCT)

services. This, in turn, limits opportunities for referral to

other HIV care and treatment in many settings, as highlighted

in a recent report by the Global Fund (2009) that PMTCT

programs continue to face major implementation challenges, as

evidenced by both poor performance and the very modest

absolute targets set by grants. These problems are linked to

important gender issues in HIV. Women often do not agree to be

tested during pregnancy, they tend to be “lost” in the

clinical and referral system and they lose access to treatment

for themselves and to prevent transmission to their children.

The situation of women and girls in the context of the HIV and

AIDS epidemic in many parts of the world and particularly sub-

Saharan Africa continues to be a cause of major concern. With

more than 30% of women in some countries reporting their first

sexual encounter as forced, and the continued feminization of

the HIV epidemic, violence remains both a cause and

consequence of HIV infection, UNICEF (2009). Once infected

with HIV, women often face varied forms of violence,

particularly driven by stigma and discrimination. Limited

access and control over resources; poor access to education

and information; limited access to services (legal, health and

social); and subordination due to harmful cultural practices

and gender inequalities, only serve to fuel this vicious cycle

of gender-based violence (GBV) and HIV and AIDS. Several best

practices have been recognized. In Botswana, the Women against

Rape organization provide medico-legal services to survivors

of violence. The group offers training in schools on the

linkages between gender based violence and HIV and human

rights and enables rural women to access legal redress for

violence (Banda: 2006). According to Kenya Demographic Health

Survey (KDHS:2008), the Men as Partners (MAP Africa) programme

works across the whole African continent to engage men through

empowering them to share responsibility of reproductive and

health rights, participate in PMTCT programmes, and prevent

violence, HIV and sexually transmitted infections (STI). Other

interventions include microfinance activities instituted to

help families aid their daily activities through venturing

into small business activities. Kibera, a Kenyan slum, has

benefited from various NGO’s that give the most vulnerable

people financial aid to aid them start small businesses to

help run their family needs (Ongech: 2007).

According to Ongech (2007), stigma and discrimination are

regarded as some of the determinants which tend to drive to

the spread of the epidemic in Kenya because they militate

against prevention and care efforts of the epidemic. Stigma

and discrimination on HIV/AIDS are complicated and

multifaceted phenomena, so that they can occur anywhere such

as in the family, the community, the school, and the workplace

and health care settings in Africa. HIV/AIDS related stigma

and discrimination are rooted in the fear of contagion

resulting from lack of in-depth knowledge on HIV/AIDS,

negative attitudes towards people living with HIV (PLHIV)

resulting from the linkage between HIV/AIDS and social taboos

such as men who have sex with men (MSM) and sex workers, and

lack of anti-discriminatory laws which can protect PLHIV and

the marginalized groups, Women Fighting Aids in Kenya (WFAK:

2005). The impact of HIV/AIDS related stigma and

discrimination is not only a barrier in responding to the

HIV/AIDS epidemic, but also a tremendous blow to economy in

Kenya. Because of fear for stigma and discrimination, people

are reluctant to take HIV testing, disclose their HIV status

to others, and seek treatment for HIV/AIDS. In Kenya, scaling

up of treatment and care has already been implemented and this

has made a big achievement. The coverage of Anti-Retroviral

Therapy (ART) and prevention of mother to child transmission

(PMTCT) is very high, which can reduce stigma and

discrimination. Also the introduction of routine HIV testing

has made a positive effect for the reduction of stigma and

discrimination.

2.3 Reducing barriers to PMTCT Services.

The Kenyan 9th National Development Plan (2002-2008) states

that “virtually all aspects of development have experienced

the severe impacts of HIV/AIDS at household, community, and

national levels. It has created shortage in manpower and also

overstretched social services, especially the health services

and the social security system.” Kenya remains among the

countries hardest hit by HIV with a prevalence rate of 9.4% in

2003 (UNAIDS: 2004). The majority of those infected are people

of reproductive age resulting in economic losses estimated at

US$3 million per day (MOH: 2001). As part of its national

HIV/AIDS strategy, the Kenya Family Planning/Reproductive

Health (FP/RH) Policy Guidelines and Standards for service

providers calls for greater integration of family planning,

sexually transmitted infections (STI), HIV/AIDS and prevention

of mother to child transmission (PMTCT) services. A major

concern of all reproductive health workers should be the rapid

increase in the prevalence of sexually transmitted infections

(STI) and HIV/AIDS. The only effective means of protection

against these infections is safe sexual practices including

abstinence and the use of barrier methods such as condoms in

addition to any other method of family planning, Ministry of

Health (MOH:2004).

The Kenyan government policy makers in the Ministry of Health

(MOH) felt the need to roll back HIV/AIDS pandemic by

integrating HIV-related counseling and services and by

providing outreach to women, men, and young people through all

possible channels. In both focus groups, HIV positive women

who receive antenatal care (ANC) and maternal child health

(MCH) services felt it was important to understand the

techniques recommended increased information on VCT and PMTCT

so that they can make informed decisions about their own

reproductive healthcare and whether to have children or not

to. According to United Nations against Acquired

Immunodeficiency syndrome (UNAIDS: 2009) one Kenyan said, “We

would want more information, and that information should be

targeted well because we are many. It should be flashed on

billboards, because most victims do not know what to do. You

can help those who do not know about re-infection, condoms;

others are only using family planning and they do not know

they can be infected. You should also advocate for VCT

services in family planning clinics”. In Kenya counseling on

prevention of mother to child transmission PMTCT is made a

mandatory requirement for all pregnant women.

According to United Nations against Acquired Immuno deficiency

Syndrome (UNAIDS: 2008), in Cambodia awareness of Voluntary

Counseling and Testing (VCT) and prevention of mother to child

transmission (PMTCT) was extremely low. Those who had accessed

VCT services said that no family planning information was

provided, but condoms were offered as protection against HIV

and sexually transmitted infections (STIs). Most HIV-positive

women, who received PMTCT services, were unfamiliar with VCT

services. This was attributed to poor attitudes of service

providers. Attitudes need to change to increase access to

services, especially for HIV-positive women who do not

disclose their status because they fear being denied

treatment.

The Ministry of Health in Kenya began offering a free

prevention of mother-to-child transmission (PMTCT) services in

a small number of antenatal clinics in January 2000. According

to Kenya Demographic Health Survey, KDHS (2000) the trial

PMTCT programme included counseling and rapid testing for all

women attending antenatal clinics and treatment for both

mother and child following a positive diagnosis. The results

of the programme after two years were fairly positive,

although there were large disparities in mother-to-child

transmission rates in different areas, which were largely

dependent on the number of staff at each facility. According

to the Ministry of Health(MOH:2006) the drugs Combivir plus

single dose Nevirapine were used for prevention of mother to

child transmission (PMTCT) in higher level facilities, while

the lower level health facilities with fewer resources

continued to use single dose nevirapine only.

According to United Nations against Acquired Immuno Deficiency

Syndrome (UNAIDS:2009), the number of prevention of mother to

child transmission (PMTCT) service delivery sites was expanded

between 2005 and 2007 with emphasis on providing services to

rural populations. The number of health facilities providing

routine HIV counseling and testing for pregnant women

increased, raising the uptake of HIV testing to 80 % of all

women attending antenatal clinics. The proportion of HIV

positive pregnant women receiving antiretroviral for PMTCT

increased from 12 % in 2005 to 53 % in 2009.

According to the United Nations General Assembly Special

Session (UNGASS:2010) latest figures, 18% of new HIV

infections in Uganda occurred through mother-to-child-

transmission(MTCT), although this figure may be higher as many

births in Uganda take place outside healthcare facilities. In

Uganda’s 2010 country progress report, prevention of mother to

child transmission (PMTCT) was placed high on the agenda with

a target of halving mother-to-child transmission (MTCT).

UNICEF (2005) indicates that an over-reliance on donor funds

can reduce the long-term sustainability of aid programmes, and

the reduced absorptive capacity of recipient countries for

such assistance often results in bottlenecks, preventing aid

packages from being used where they are most needed. As a

result, despite higher levels of acceptance of aid by certain

governments, a global climate of increased political stability

and economic growth, and greater public access to information

and advocacy, inequitable access to treatment and prevention

persists. While challenges experienced by households and

communities in terms of providing resources for home-based

care are also significant hindrances to the effective delivery

of care, shortcomings inherent in health systems constitute

the major blocks in channeling the ever-increasing amounts of

aid to those most in need. It follows that inequities in the

provision of healthcare services may escalate in the coming

years unless efficiency is coupled with justice in the

construction of national health systems.

According to United Nations against Acquired Immuno Deficiency

Syndrome (UNAIDS:2007), constraints relating to supply within

health systems, including finance, information systems, human

resources, drugs and logistics as well as those on the demand-

side, such as increased patient numbers, stigma and

discrimination among communities hinder progress of prevention

of mother to child transmission services (PMTCT). The example

of introducing prevention of mother to child transmission

(PMTCT) programmes, which are among the simplest and most

cost-effective of anti- HIV programmes available, into

national health systems, is illustrative of the challenges

faced by developing countries. Single dose Nevirapine (a dose

each to mother during delivery and to her newborn) is the most

widely used regimen for PMTCT, having the advantages of

simplicity, affordability, and effectiveness. Most programmes

and agencies, including UNICEF, the Elizabeth Glaser Pediatric

AIDS Foundation (EGPAF), and state authorities, have found

that in developing countries, of the women who should be given

ART, only a minority receive the drugs. Even fewer infants are

given their prophylactic dose of Nevirapine. Until recently,

experience suggested that, despite wide variations between

countries, in general, of the HIV positive women attending

antenatal clinics, probably less than 20% received anti retro

viral therapy (ART). According to Walker: 2009 of the 2.1

million pregnant women who are HIV positive in any given year

globally, (excluding high-income countries), only 200,000

receive PMTCT interventions.

According to United Nations against Acquired Immuno Deficiency

Syndrome (UNAIDS: 2008) uptake of prevention of mother to

child transmission services is improving. Data from studies

undertaken in Kwazulu Natal, South Africa - a region severely

affected by the epidemic - show that, for 150,000 deliveries

per annum, prevention of mother to child transmission (PMTCT)

coverage increased from 10% in 2001 to 78% in 2003/04.United

Nations against Acquired Immuno Deficiency Syndrome

(UNAIDS :2008) suggests that in order to build capacity, an

approach which incorporates training, technical assistance and

access to improved guidelines and tools should be adopted by

funders. In order to utilize resources effectively recipient

countries need to undertake thorough planning processes

whereby goals relevant to that country are set and allocation

of funds is made according to need.

According to United Nations against Acquired Immune Deficiency

Syndrome (UNAIDS :2009), the scale and nature of the HIV

epidemic is such that it is generally the most pressing health

challenge faced by developing countries. As such, an approach

specific to the disease itself could be seen as the most

effective way of building the capacity of health systems in

countries of need, as it may be a more manageable way to

address weaknesses in the health system while at the same time

delivering short-term returns. This approach can, however,

result in parallel systems being set up, and can cause

disruptions in day to day healthcare provision. There are

multiple overlaps in the health service requirements for

HIV/AIDS and those for other diseases, which constitute a

compelling argument to avoid as far as possible vertical

schemes for HIV prevention and treatment interventions. A

system-wide response has the advantage of addressing a wider

range of diseases, and draws attention to other health

challenges that may be overlooked in the context of HIV/AIDS.

Although the results of this approach may not be as quickly

seen as in the disease-specific approach, it allows the system

in its entirety to be strengthened.

CHAPTER THREE

RESEARCH DESIGN AND METHODOLOGY

3.1 Introduction.

This chapter contained the research methodology. These are the

research methods that will be used in carrying out the

research study. It included research design, research site,

population, sampling techniques, research instruments, and

data collection procedures and data analysis.

3.2 Research design

A research design holds all the elements in a research project

together. It is used to structure the research, to show how

all the major parts of the research project work together to

try and answer the central research questions, Orodho (2003).

The researcher used descriptive research design. This was

because the respondents were expected to explicitly describe

factors hindering prevention of mother to child transmission

(PMTCT) services in public hospitals and overall effect on HIV

management. According to Cooper and Schinder (2001),

descriptive research design involves answering such questions

as who, how, what, which, when and how much.

Descriptive research purposes to describe the state of affairs

as it is at that particular time. According to Kombo and Tromp

(2006), descriptive studies are not only restricted to fact

findings but may often result in the formulation of important

principles of knowledge and solutions to significant problems.

They involve measurement, classification, analysis, comparison

and interpretation of data.

3.3 Research Instrumentations 3.3.1 Questionnaires

According to Zikmund (2003), a questionnaire is a research

instrument consisting of a series of questions and other

prompts for the purpose of gathering information from

respondents.

3.3.2 Interviews

Interviews are a one on one session where the interviewer gets

to ask the interviewee questions.

3.4 Target population.

According to Mugenda and Mugenda (2003), population refers to

the entire group of individuals, events or objects having

common observable characteristics. The target population was

the pregnant and lactating mothers and the para medical staff

of Kenyatta National Hospital antenatal and postnatal care.

The main focus will be on medical officers, pharmacist,

pregnant mothers, lactating mothers and nurses.

Specific characteristics are given below in Table 3.1

Table 3.1 Population size

Category Population size PercentageDoctors 5 5Nurses 15 15Pharmacists 6 6Pregnant

mothers

52 52

Lactating

mothers

22 22

Total 100 100

3.5 Sample design.

From the above population of 100, random sampling of 50

respondents was taken for the research. According to Mugenda

and Mugenda (1999), a representative sample is one that

represents at least 10% of the population of interest. The

method was used to pick the sample which would show the

probability sampling method. Stratified random sampling was

used which involved dividing the population into homogeneous

subgroups and then taking a simple random sample in each

subgroup. This method gave every unit in the sample a chance

of being included in the study. See Table 3.2 below.

Table 3.2 Sample population

Category Population

size

Sample

size

Percentage

Doctors 6 3 6Nurses 14 8 16Pharmacist

s

6 3 6Pregnant

mothers

52 26 52Lactating

mothers

22 10 20Total 100 50 100

3.6 Data collection procedures.

Data collection refers to the gathering of information to

serve proof or refute some facts. Data collection was

important in this research because enabled the dissemination

of accurate information and the development of meaningful

prevention of mother to child transmission (PMTCT) programs.

Data was collected from both primary and secondary sources.

Collection of primary data involved questionnaires. The

questionnaires were given to the target population to fill and

questions asked to the selected sample. According to Mugenda

and Mugenda, (1999) a questionnaire is a research instrument

consisting of a series of questions and other prompts for the

purpose of gathering information from respondents. Interviews

are a one on one session where the interviewer gets to ask the

interviewee questions.

The secondary method of data collection used was the

internet, books on drugs PMTCT management, journals of related

researches on PMTCT and magazines from KNH. The importance of

secondary data collection was to get the view of the people

who have knowledge in the subject and people who the

researcher did not have a chance to meet. Books are only

intercourse between the writer and the reader.

ACTIVITIES. DURATION.Proposal writing 4 weeksEthical approval 2-3 weeksData collection 2 weeksData analysis 2 weeksReport writing 2 weeksResearch presentation 1 week.

3.8 Data Analysis.

After collecting the data by use of questionnaires from

the respondents, it was edited, classified and coded and

tabulated. Computer packages such as SPSS (Social Package

for Statistical Sciences), and excel were used to analyze

the data. The data was presented informatively using graphs,

pie charts and tables.

CHAPTER FOUR

DATA ANALYSIS PRESENTATION AND INTERPRETATION

4.1 Introduction

This chapter discusses the data analysis and interpretation.

The data presentation is guided by the study objectives. The

study sought to identify the factors that hinder the success

of the prevention of mother to child transmission of HIV

infection during pregnancy, labor, and delivery and in

breastfeeding at Kenyatta National Hospital. The study

focused on personal and community factors and also ways that

can be used to enhance dissemination of information on the

prevention of mother to child transmission of HIV. Data was

collected using questionnaires which were administered to

the study sample. The findings were presented in the form of

Tables, Charts, Graphs, Tautology and Percentages. These

findings are based on the responses obtained from the

returned questionnaires.

4.2 Demographic information 4.2.1 Gender of the respondents

The Pie Chart below shows the gender of the

respondents.

Figure 4.1 Gender

From the above Figure 4.1, the majority (75%) of the

respondents were female, while 25% were male. This indicates

that antenatal and postnatal care is largely done by women.

4.2.3 Age of the Respondents

The age of the respondents is shown by the Bar Chart below

Years

Figure 4.2 Age bracket

Figure 4.2 above shows that the majority (55%) of the

respondents was between 20-30 years and 20% were between 31-

40 years. The minority 25% were aged between 41-50 years.

This indicated that child bearing age is usually between 20-

35 years as indicated by most of the respondents.

4.2.4 The respondents’ Marital Status

The marital status of the respondents is show by the

Bar Chart below

Figure 4.3 Marital status

Figure 4.3 shows that majority (50%) of the respondents were

married, 38% of them were single, while the minority (12%)

were either divorced or separated.

4.2.4 Education level of the respondents

This part of the study sought to establish the education

level of the respondents as shown by Figure 4.4 below.

Figure 4.4: Shows education level of the respondents.

Figure 4.4 above shows that the respondents did not have a

high level of education with the majority (63%) having

attained primary and secondary level of education while only

8% of the rest had acquired university level of education.

4.3 Personal Factors

This section of the study sought to establish the

number of antenatal clinics attended since conception.

4.3.1 Antenatal Clinics Attended since Conception

Figure 4.5 Number of antenatal clinics attended.

Figure 4.5 shows that majority (50%) of the respondents had

attended two clinics while 20% had attended more than three.

The rest had attended either one clinic or none at all. This

is an indication that there is need for more awareness on

antenatal clinic attendance.

4.3.2 Knowledge of HIV Status before Visiting the

Clinic.

This section sought to identify whether the respondents knew

their HIV status before visiting the clinic as shown by

Figure 4.6 below.

Figure 4.6: Knowledge of HIV status before visiting the

clinic

Figure 4.6 above indicates that majority (80%) of the

respondents did not know their HIV status before visiting

the antenatal clinic while the rest (20%) knew their status.

It would appear that despite government campaigns for

individuals to find out their HIV status through Voluntary

Counseling and Testing (VCT) a lot of people are still not

responding to this campaigns and hence voluntary testing is

still very low Nature of the testing process

This part of the study sought to find out the nature of the testing process

to the respondents as shown by the Pie Chart below.(Figure

4.7)

Figure 4.7 Nature of the testing process

Figure 4.7 above shows that majority (62%) of the

respondents found the testing process unfriendly while 38%

found it friendly. It appears that this unfriendliness keeps

the expectant mothers away from the testing process.

4.3.5 Knowledge about HIV/AIDS and its

transmissionThis section sought to find out whether the

respondents had any knowledge on the different modes of

transmission of HIV/AIDS as indicated by the figure below.

Figure 4.8: Shows knowledge about HIV/AIDS and its

transmission.

From Figure 4.8 above it emerges that majority (71%) of the

respondents did not have knowledge about HIV/AIDS

transmission while 29% had some knowledge of the mode of

transmission. This implies that there is need for more

public sensitization and awareness on HIV/AIDS and the

different ways of transmission.

4.3.6 Services provided upon the affirmation of your HIV

status

This part of the study sought to rate the respondents

attitude towards the services provided upon affirmation of

their HIV status. The results indicated that the services

provided by the health care professionals upon affirmation

of the HIV status were extremely dissatisfying. The

attention the respondents got upon affirmation of their HIV

status was very poor and their needs were not met promptly.

This means that the health care providers need to be more

humane and show unconditional positive regard while dealing

with HIV positive clients.

4.3.7 Clinic environment

This section of the study sought to rate the clinic

environment. The results showed that the clinic was poorly

ventilated and unclean, the service providers were not

attractive and the information displayed on the walls’. Was

not satisfactory. This implies that the environment needs to

be made more conducive for the provision of services for the

prevention of mother to child transmission of HIV.

4.4 Social Cultural (Community Factors)

4.4.1 Community behavior towards a HIV positive person

This part of the study sought to identify the behavior of

the community towards a HIV positive person. Majority of the

respondents indicated that the community exhibited

unfriendly behavior towards a HIV positive person. This

shows that there is need to create more public awareness so

as to educate the community on HIV/AIDS and hence reduce the

stigma associated with the disease.

4.4.2 Reaction of partner/spouse upon realizing one is

HIV positive

This section sought to find out the reaction of the

spouse or partner of a HIV positive person as indicated in

Table 4.4 below.

Frequency PercentageFriendly 16 40%Hostile 24 60%Table 4.1 Reaction of the partner/spouse upon realizing

one is HIV positive

Table 4.4 shows that majority (60%) of the respondents

indicated that the reaction of their partner/spouse upon

realizing one is HIV positive was hostile while only 40% of

the respondents indicated that the reaction of

partner/spouse upon realizing one was HIV positive was

friendly. This means that destigmatization of HIV/AIDS is

very important if the war against mother to child

transmission of HIV is to won.

4.4.3 Public Disclosure about the Respondents HTV

statusThis section of the study sought to identify the

respondents attitude towards disclosing their HIV status to

their significant others. The results are shown in Figure

4.9 below.

Figure 4.9 Public Disclosure about the Respondents HIV

status

Figure 4.9 above shows that majority (57%) of the

respondents would not like to have their HIV status known by

anybody besides themselves and those testing them. This

means that there is need for greater public awareness on HIV

as a disease. It is also critical to educate HIV positive

spouses on the need to disclose the information significant

others - who usually will form the support system.

4.4 5 Beliefs in the Community Associated with the HTV

disease

This section of the study sought to establish whether

there are any community beliefs associated with HIV disease

which affect pregnant mothers. The results are shown in the

Pie Chart below.

Figure 4.10 Beliefs in the Community Associated with

the HIV disease

Figure 4.10 above shows that majority (56%) indicated

that HIV is associated with prostitution which made the

mothers to be segregated by the community. The minority

(44%) indicated that their communities do not have any

beliefs associated with HIV as a disease that affect the

pregnant mothers.

4.5 Dissemination of Information on prevention of

mother to child transmission of HIV by the Service Providers

4.5.1 Availability of private rooms for counseling

This part of the study sought to establish whether

there were private rooms for counseling of the HIV positive

mothers and their significant other persons. This

information is shown in Figure 4.12 below.

Figure 4.11 Availability of private rooms for

counseling

Majority of the respondents (90%) indicated that there

were private rooms for counseling. This shows the

government’s commitment to ensuring that HIV positive

mothers get the psychosocial support they require.

4.5.2 Confidentiality of the test result

This section sought to establish whether the test

results of a HIV positive mother were held as confidential

or displayed on the notice board for public viewing and

scrutiny. The information is shown in Figure 4.12 below.

Figure 4.12 Confidentiality of the test result

Figure 4.12 above shows that the results on the HIV

status of the mothers was kept confidential as the majority

(99%) of the respondents indicated. This is in line with the

law and ethics that demands that information on an

individual’s HIV status should be kept confidential and only

revealed with her consent.

4.5.3 Means of communication put in place to relay

information on prevention of mother to child transmission of

HIV/AIDS

This section of the study sought to establish the means

of communication that the hospital has put in place for

relaying information on the prevention of mother to child

transmission of HIV/AIDS. The results showed that print

materials such as wall charts and brochures are the largest

means of communication used in public hospitals. Other means

of communication in use include individualized counseling,

group counseling, video shows and short skits.

4.5.5 Counseling done to HIV positive pregnant mothers

in relationship to the unborn babies

The study sought to establish the areas which are

emphasized on in counseling HIV positive pregnant mothers in

relationship to the unborn babies.

Figure 4.13 Counseling HIV positive pregnant mothers in

relationship to the unborn babies

Figure 4.13 above shows that pregnant mothers are

counseled more on breastfeeding (36%), adherence to medicine

instructions, (22%) and nutrition (22%). It also shows that

good sexual behavior is emphasized as indicated by 20% of

the respondents.

CHAPTER FIVE

DISCUSSION, CONCLUSION AND RECOMMENDATION

5.1 Introduction

This chapter provides a summary and discussions of the key

findings of the study, conclusions and the recommendations. The

summary and discussion follow the research questions which guided

the investigations of this study. It also gives the conclusions

and recommendations as drawn from the data analysis in chapter

4.The purpose of the study was to find out the personal factors,

identify community (social cultural) factors that hinder the

success of Prevention of Mother to Child Transmission of HIV

services (PMTCT) in public hospitals and identify ways that can

be used to enhance dissemination of information on Prevention of

Mother to Child Transmission of HIV in these institutions.

5.2 Summary of the findings

The findings of the study were that the personal and community

factors that affect prevention of mother to child transmission of

HIV are that antenatal clinic attendance is adhered to. Prior

knowledge of ones HIV status before conception was poor. The HIV

testing process as considered unfriendly by the majority of the

respondents.

Upon the affirmation of the respondents HIV status, most of the

services provided were unsatisfactory according to the results

obtained from respondents. The clinic environment was also found

to be dissatisfying due to poor ventilation, uncleanliness and

the unattractiveness of the service providers. The HIV

information charts displayed on the walls were also

dissatisfying.

The community factors were that behavior towards HIV positive

pregnant mothers is unfriendly since the disease is regarded as

one infecting prostitutes only while spouses/partners were shown

to be hostile. Majority of the respondents preferred their

results kept secret while the minority preferred discussing their

results with their significant others.

Results also indicated that counseling of the HIV positive

mothers is done in private rooms which ensures confidentiality of

the client’s information.

The largest means of communication put in place to relay

information on prevention of mother to child transmission of

HIV/AIDS is print materials such as wall charts and brochures

whereas other means such as group counseling, video shows and

individualized counseling are also used.

Counseling of the mothers concentrates more on proper adherence

to medicine instructions, exclusive breastfeeding and nutrition,

while alternative feeding and good sexual behavior is also

emphasized.

5.3 Conclusion

There are several personal factors that hinder the success of

Prevention of Mother to Child Transmission (PMTCT) services in

public hospitals as the study found out such as community

beliefs, stigma, and attitude of the care givers among others.

Hospitals have put in place various methods for disseminating

information on Prevention of Mother to Child Transmission of HIV

which if well utilized can raise public awareness on mother to

child transmission of HIV and how to prevent it.

5.4 Recommendations

The study recommends that for mother to child transmission of HIV

to be overcome there should be more emphasis on individual and

group counseling. There should be more public awareness on HIV as

a disease so as to destigmatize it; and voluntary counseling and

testing (VCT) should be encouraged by the government.

The attitude of the care givers should be positive so as to

encourage more mothers to attend the antenatal clinics. 

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APPENDIX I QUESTIONNAIRE

This questionnaire aims at gathering data on the process of

prevention of mother to child transmission of HIV infection

during pregnancy, labour, delivery and through breastfeeding in

Kenyatta National Hospital. The information required is purely

for academic purposes at the university of Nairobi where am

currently pursuing a degree course in counseling psychology. This

information will be treated with the highest level of

confidentiality.

Section A: Background of the Respondent

1) Indicate your gender

Male ( ) Female ( )

2) What is your age bracket in years?

a) 20-30 b) 31-40 c) 41-50 d) Above 50 years

3) What is your marital status?

a) Married b) Single c) Divorced d) Separated

4) What is your level of education?

a) Primary b) Secondary c) College d) University

Section B: Personal Factors of the Respondent

1) How many antenatal clinics have you attended since you

conceived?

a) None b) Two c) One d) More than three

2) How many are you required to attend in total before the

delivery date? (One, more than one specify)

3) Did you know your HIV status before visiting the

clinic? Yes ( ) No ( )

4) Were you tested for HIV on your first visit? Yes ( ) No

( )

5) How did you feel when you were informed that testing

your HIV status was a basic requirement in the

hospital? (a) Afraid (b) indifferent Explain briefly

the reasons of you feelings.

6) What was the testing process like, friendly or

unfriendly?

7) What results did you anticipate?

(a) Positive (b) negative (c) don’t know

8) Do you know anything about HIV/AIDS and its

transmission? ( yes, no)

9) About services provided upon the affirmation of your

HIV status, how satisfied are you with the

following: Indicate either (a) extremely satisfied (b) satisfied

(c) dissatisfied (d) extremely dissatisfied

• Grooming and appearance of service provider like the

nurse, doctor or the pharmacist

• Promptness in attending to your needs

• Attentiveness

• Warmth and friendliness

10) About the environment in the clinic how are you

satisfied with the following?

• Ventilation and cleanliness of the clinic

• Attractiveness of the service providers

• The HIV information charts displayed on the walls

Section C: Social Cultural (Community Factors)

1) How does your community behave towards a HIV positive

person? a) Friendly (b) unfriendly

2) What do you expect to be the reaction of your

partner/spouse upon realizing that you are HIV

positive? (a) Friendly (b) hostile

3) Would you like other members of your family or even

community to know your HIV status? a) Yes b) No

briefly explain your answer.

4) How do you intend to counter the reaction of your

partner/ spouse or any other significant person in

your life?

a) Keep your HIV results secret (b) discuss the results

with him

5) Are there any beliefs in your community associated with

the HIV disease which you feel you have to contend

with? (a) Yes (b) No Explain briefly. 

Section D: Dissemination of Information by the Service

Providers

1) Do you have private rooms for counseling? a) yes b) no

c) don’t know

2) Do you maintain confidentiality? a) yes b) no c)

somehow d) don’t know

3) What means of communication have been put in place to

relay information on prevention of mother to child

transmission of HIV/AIDS? Tick as appropriate:

a) Individualized counseling

b) Group counseling

c) Print materials such as wall charts and brochures

d) Video shows

e) Short skits

4) To what extent are the patients counseled on the

following areas:

A) Exclusive breastfeeding (a) large extent (b) moderate

extent (c) not counseled at all

B) Alternative feeding (a) large extent (b) moderate

extent (c) don’t know

C) Proper adherence to medicine instructions a) large

extent (b) small extent c) not at all.

5) Which areas do you emphasize on when dealing with HIV

positive pregnant mothers in relationship to the unborn babies?

a) Breastfeeding b) adherence to medicine instructions c)

nutrition d) good sexual behavior e) non at all

6) Are there any challenges the hospital is facing in its

efforts to tame the spread of HIV from mother to child ?Tick as

appropriate

a) Non adherence to antiretroviral therapy ( yes, no ,

don’t know)

b) Irregular clinic attendance (yes, no, don’t know)

c) Others specif}'

7) Are there any strategies you have put in place to

manage these challenges? (a) Yes (b) no (c) don’t know

8) Make some suggestions on the best way to improve

interpersonal relationship between the health care provider and

the HIV positive client so as to enhance the prevention of mother

to child transmission of HIV infection in this hospital.