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.
REFERENCES
Brooks, J. J, et al. (2002). “Intrapartum and neonatal single-
dose Nevirapine compared with zidovudine for prevention of
mother-to-child transmission of HIV.” In Kampala, Uganda:
Dabis, F. et al. (1999). “Six-month efficacy, tolerance, and
acceptability of a short regimen of oral zidovudine to reduce
vertical transmission of HIV in breastfed children. ” In Cote
d'Ivoire and Burkina Faso, pp353:786-792.
Fawzi, W. Msamanga, G. & Hunter, D. (2000). “Randomized tried of
vitamin supplements in relation to vertical transmission of HIV-
1. In Tanzania.
Fawzi, W. Msamanga, G. and Renjifo, B.(2001). “Predictors of
intrauterine and intrapartum transmission of HIV among Tanzanian
women”. Tanzania, ppl5:l 157-1165.
Gregson, S. Nyamukapa, C.& Garnett, G. (2005). “HIV infection and
reproductive health in teenage women orphaned and made vulnerable
by AIDS.” In Zimbabwe, vol 7 pp785-94.
Jamieson, D. Sibailly, S. & Sadek, R. (2003). “HIV-1 viral load
and other risk factors for mother-to-child transmission in a
breastfeeding population in Cote d'Ivoire”. Publication34 pp 430-
436.
Joint United Nations Programme on HIV/AIDS (UNAIDS), (2006)
Report on the Global AIDS Epidemic. Geneva and New York
Kilewo, C. Karlsson, K. & Massawe, A. (2008). “Prevention of
mother-to-child transmission of HIV-1 through breast-feeding by
treating infants’ prophylactically with lamivudine”. Dar es
Salaam, Tanzania publication 48 pp 315-323.
Kilewo, C. Karlsson, K. & Ngarina, M. (2009). “Prevention of
mother-to-child transmission of HIV-1 through breastfeeding by
treating mothers with triple antiretroviral therapy”. Dar es
Salaam, Tanzania publication 52 pp 406-416.
Kumwenda, N., Miotti, G. & Taha, E. (2002). “Antenatal vitamin A
supplementation increases birth weight and decreases anemia among
infants born to human immunodeficiency virus-infected women”.
Malawi. Publication 35 pp 618-624.
Lallemant, M. Jourdain, G. & Le Couer, S. (2000). “A trial of
shortened zidovudine regimens to prevent mother-to-child
transmission of human immunodeficiency virus type 1 N England
pp343, 982-991.
Lallemant, M. Jourdain. G. & Le Coeur, S. (2004). “Single dose
perinatal nevirapine plus standard zidovudine to prevent mother
to child transmission of HIV-1 ”. Thailand, pp 351, 217-228.
Mugenda,0. and Mugenda, A. (2003). Research Methods. Nairobi:
Acts Press.
Nduati, R. John, G. & Mbori-Ngacha, D. (2000). “Effect of
breastfeeding and formula feeding on transmission of HIV-1 ”.
JAMA pp283, 1167-1174.
Nduati. R. Richardson, A. & John, G. 2001. “Effect of
breastfeeding on mortality among HIV-1 infected women”. Lancet:;
pp357, 1651-1655.
Peltier, A. Ndayisaba, F. & Lepage, P. (2009). “Breastfeeding
with maternal antiretroviral therapy or formula feeding to
prevent HIV postnatal mother-to- child transmission”. In Rwanda.
Publication 23 pp2415-2423.
Shapiro, L. Hughes, D. & Ogwu, A. (2010). “Antiretroviral
regimens in pregnancy and breast-feeding in Botswana”. England pp
362, 2282-2294.
Working Group on MTCT of HIV (1995). “Rates of mother-to-child
transmission of HIV-1.” In Africa, America and Europe: vol 8
pp506-510.
World Health Organization (2009). Rapid advice: use of
antiretroviral drugs for treating pregnant women and preventing
HIV infection in infants. November.
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.
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