Reasons for and Determinants of NonAdherence to the PMTCT Program in Rwanda Thrse Delvaux, Batya Elu

1
Poster 75

Reasons for and Determinants of Non-Adherence to
the PMTCT Program in Rwanda Thérèse Delvaux,
Batya Elul, Felix Ndagije? (presenting author),
Elevanie Munyana, Dominique Roberfroid, Vianney
Nizeyimana, and Ruben Sahabo? Institute of
Tropical Medicine, Antwerp, Belgium Internationa
l Center for AIDS Care and Treatment Programs,
Columbia University, Mailman School of Public
Health, New York, NY USA ?International Center
for AIDS Care and Treatment Programs, Columbia
University, Mailman School of Public Health,
Kigali, Rwanda Treatment and Research AIDS
Center, Ministry of Health, Kigali, Rwanda
BACKGROUND
RESULTS, continued

• Adequate access to, uptake of and adherence to
  pMTCT services is required for effective
  prevention of perinatally acquired HIV
• Previous studies have suggested a number of
  potential barriers to successful use of pMTCT
  services including
• Negative attitudes towards HIV testing
• HIV-related stigma
• Lack of community involvement
• Poor provider-client interactions
• Poor quality of care in antenatal and obstetric
  services
• Barriers to access and utilization of the pMTCT
  program in Rwanda have not been systematically
  evaluated
• The Rwandan national pMTCT program is currently
  shifting from a single-dose Nevirapine (SD-NVP)
  regimen to more complex prophylaxis regimens
• Identifying determinants of adherence to the
  existing SD-NVP regimen can inform the roll-out
  of new regimens

Fig. 1 Types of non-adherence in mother-infant
pairs
47.0
42.0
5.5
5.5
DESIGN/METHODS

• Cross-sectional survey at 12 nationally
  representative pMTCT sites (all using SD-NVP
  pMTCT prophylaxis regimen) selected using
  multi-stage sampling techniques
• Closed-ended interviews with 236 HIV-positive
  women (125 adherent and 111 non-adherent) who
  received pMTCT services at site during their last
  pregnancy
• Adherence defined as mother-infant pairs
  ingesting SD-NVP at the recommended time (e.g. at
  the onset of/during labor for mothers and within
  72 hours of delivery for infants)
• Number of adherent and non-adherent women fixed
  by design
• Women sampled from ANC registers, contacted at
  home by site staff not affiliated with the study
  and invited to return to the clinic for an
  interview
• Descriptive statistics used to compare
  experiences and outcomes among adherent and
  non-adherent women
• Multivariate analysis used to examine
  determinants of mothers and infants not ingesting
  SD-NVP, as well as of intermediate variables in
  the pathway to adherence. Five outcomes measures
  analyzed in separate multivariate logistic
  regression models, which controlled for all
  variables significant at 0.10 level in bivariate
  models, and maternal age and study site
• Model 1 Not receiving SD-NVP during pregnancy
  (i.e. before the expected date of delivery)
• Model 2 Not delivering in a health facility
• Model 3 Mother and/or infant not ingesting
  SD-NVP at all or at the recommended time
• Model 4 Mother not ingesting SD-NVP at all or
  at the recommended time
• Model 5 Infant not ingesting SD-NVP at all or
  at the recommended time

Fig. 3 Discussions regarding SD-NVP with
partner, among women who received it, by
adherence status
Fig. 4 Maternal ingestion of SD-NVP(among women
who received it), by adherence status

If discussed taking SD-NVP with partner
If ingested SD-NVP, timing of ingestion
Fig. 5 Newborn ingestion of SD-NVP, by
adherence status and place of delivery
RESULTS
Fig. 6 If woman delivered at home, newborn
brought to health facility for SD-NVP, by
adherence status

• Types of non-adherence among 111 non-adherent
  mother-infant pairs (Fig. 1)
• Neither mother nor child took NVP (42.0)
• Mother took NVP but child did not (47.0)
• Only child took NVP (5.5)
• Mother and/or child took NVP but not at
  recommended time
• Receipt of NVP and decision-making (Fig. 2 and
  3)
• All adherent women received NVP from a health
  worker during pregnancy or delivery vs. 61 of
  non-adherent women
• Most women discussed taking NVP with their
  partners, and many waited for their partners
  permission before making a decision about it
• 9 of non-adherent women said partners were not
  supportive of their taking the drug
• Maternal ingestion of NVP (Fig. 4)
• All adherent women (per definition) ingested NVP
  vs. 85 of non-adherent women who received it
• Many non-adherent women who ingested it did so
  after or before the onset of labor
• 40 said this was because a health provider told
  them to do so and another 17 said this was
  because they did not receive specific
  instructions about when to take it
• Non-adherent women who received the ARV
  prophylaxis but did not take it at all reported
  this was because they had forgotten to do so
  (30) or were afraid to take it (30), their
  labor had progressed too quickly (20) or because
  their husband was present (and presumably they
  had not disclosed their HIV-status) (20)
• Newborn ingestion of NVP (Fig. 5 and 6)
• Newborns of all adherent women (per definition)
  took NVP vs. 7 of infants of non-adherent women

If newborn brought to facility, timing of visit



CONCLUSIONS

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

ACKNOWLEDGEMENTS

• The Government of Rwanda
• U.S. Centers for Disease Control and Prevention
• Elizabeth Glaser Pediatric AIDS Foundation
• Site staff, study interviewers and participants