Alemnesh Hailemariam Mirkuzie

Promising outcomes of a national programme for the prevention of mother-to-child HIV transmission in Addis Ababa: a retrospective study

BackgroundPrevention of Mother-to-Child HIV Transmission (PMTCT) is still the most effective intervention in combating new HIV infections. In 2008, revised national PMTCT guidelines that incorporated new policies on HIV counselling and testing, antiretroviral prophylaxis regimen and infant HIV diagnosis came into effect in Ethiopia. In the present study we have examined trends in PMTCT service utilization and assessed the rate of MTCT in relation to policy changes in the national PMTCT programme.MethodsReports from February 2004 to August 2009 were reviewed in 10 sub-cities in Addis Ababa, Ethiopia. The data was collected from May to October 2009.ResultsThe proportion of women who received HIV counselling and testing among new antenatal care attendees increased from 50.7% (95% CI 50.2-51.2) in 2007 to 84.5% (95% CI 84.1-84.9) in 2009 following the shift to routine opt-out testing. Nevertheless, in 2009 only 53.7% of the positive women and 40.7% of their infants received antiretroviral prophylaxis. The HIV prevalence among antenatal attendees decreased significantly from 10.5% in 2004 to 4.6% in 2009 in parallel to the increased number of women being tested. The HIV positive women were over 18 times (RR 18.5, p < 0.0001) more likely to be referred for treatment, care and support in 2009 than in 2004. The proportion of partners tested for HIV decreased by 14% in 2009 compared to 2004, although the absolute number was increasing year by year. Only 10.6% (95% CI 9.9-11.2) of the HIV positive women completed their follow up to infant HIV testing. The cumulative probability of HIV infection among babies on single dose nevirapine regimen who were tested at >=18 months was 15.0% (95% CI 9.8-22.1) in 2007, whereas it was 8.2% (95% CI 5.55-11.97) among babies on Zidovudine regimen who were tested at >=45 days in 2009.ConclusionThe paper demonstrates trends in PMTCT service utilization in relation to changing policy. There is marked improvement in HIV counselling and testing service utilization, especially after the policy shift to routine opt-out testing. However, despite policy changes, the ARV prophylaxis uptake, the loss to follow up and the partner testing have remained unchanged across the years. This should be a matter of immediate concern and a topic for further research.

Current status of medication adherence and infant follow up in the prevention of mother to child HIV transmission programme in Addis Ababa: a cohort study

BackgroundPrevention of mother to child HIV transmission (PMTCT) programmes have great potential to achieve virtual elimination of perinatal HIV transmission provided that PMTCT recommendations are properly followed. This study assessed mothers and infants adherence to medication regimen for PMTCT and the proportions of exposed infants who were followed up in the PMTCT programme.MethodsA prospective cohort study was conducted among 282 HIV-positive mothers attending 15 health facilities in Addis Ababa, Ethiopia. Descriptive statistics, bivariate and mulitivariate logistic regression analyses were done.ResultsOf 282 mothers enrolled in the cohort, 232 (82%, 95% CI 77-86%) initiated medication during pregnancy, 154 (64%) initiated combined zidovudine (ZDV) prophylaxis regimen while 78 (33%) were initiated lifelong antiretroviral treatment (ART). In total, 171 (60%, 95% CI 55-66%) mothers ingested medication during labour. Of the 221 live born infants (including two sets of twins), 191 (87%, 95% CI 81-90%) ingested ZDV and single-dose nevirapine (sdNVP) at birth. Of the 219 live births (twin births were counted once), 148 (68%, 95% CI 61-73%) mother-infant pairs ingested their medication at birth. Medication ingested by mother-infant pairs at birth was significantly and independently associated with place of delivery. Mother-infant pairs attended in health facilities at birth were more likely (OR 6.7 95% CI 2.90-21.65) to ingest their medication than those who were attended at home. Overall, 189 (86%, 95% CI 80-90%) infants were brought for first pentavalent vaccine and 115 (52%, 95% CI 45-58%) for early infant diagnosis at six-weeks postpartum. Among the infants brought for early diagnosis, 71 (32%, 95% CI 26-39%) had documented HIV test results and six (8.4%) were HIV positive.ConclusionsWe found a progressive decline in medication adherence across the perinatal period. There is a big gap between mediation initiated during pregnancy and actually ingested by the mother-infant pairs at birth. Follow up for HIV-exposed infants seem not to be organized and is inconsistent. In order to maximize effectiveness of the PMTCT programme, the rate of institutional delivery should be increased, the quality of obstetric services should be improved and missed opportunities to exposed infant follow up should be minimized.

Applying the theory of planned behaviour to explain HIV testing in antenatal settings in Addis Ababa - a cohort study

BackgroundTo facilitate access to the prevention of mother-to-child HIV transmission (PMTCT) services, HIV counselling and testing are offered routinely in antenatal care settings. Focusing a cohort of pregnant women attending public and private antenatal care facilities, this study applied an extended version of the Theory of Planned Behaviour (TPB) to explain intended- and actual HIV testing.MethodsA sequential exploratory mixed methods study was conducted in Addis Ababa in 2009. The study involved first time antenatal attendees from public- and private health care facilities. Three Focus Group Discussions were conducted to inform the TPB questionnaire. A total of 3033 women completed the baseline TPB interviews, including attitudes, subjective norms, perceived behavioural control and intention with respect to HIV testing, whereas 2928 completed actual HIV testing at follow up. Data were analysed using descriptive statistics, Chi-square tests, Fishers Exact tests, Internal consistency reliability, Pearsons correlation, Linear regression, Logistic regression and using Epidemiological indices. P-values < 0.05 was considered significant and 95% Confidence Interval (CI) was used for the odds ratio.ResultsThe TPB explained 9.2% and 16.4% of the variance in intention among public- and private health facility attendees. Intention and perceived barriers explained 2.4% and external variables explained 7% of the total variance in HIV testing. Positive and negative predictive values of intention were 96% and 6% respectively. Across both groups, subjective norm explained a substantial amount of variance in intention, followed by attitudes. Women intended to test for HIV if they perceived social support and anticipated positive consequences following test performance. Type of counselling did not modify the link between intended and actual HIV testing.ConclusionThe TPB explained substantial amount of variance in intention to test but was less sufficient in explaining actual HIV testing. This low explanatory power of TPB was mainly due to the large proportion of low intenders that ended up being tested contrary to their intention before entering the antenatal clinic. PMTCT programs should strengthen womens intention through social approval and information that testing will provide positive consequences for them. However, womens rights to opt-out should be emphasized in any attempt to improve the PMTCT programs.

Current evidence on basic emergency obstetric and newborn care services in Addis Ababa, Ethiopia; a cross sectional study

BackgroundEmergency obstetric and neonatal care (EmONC) is a high impact priority intervention highly recommended for improving maternal and neonatal health outcomes. In 2008, Ethiopia conducted a national EmONC survey that revealed implementation gaps, mainly due to resource constraints and poor competence among providers. As part of an ongoing project, this paper examined progress in the implementation of the basic EmONC (BEmONC) in Addis Ababa and compared with the 2008 survey.MethodsA facility based intervention project was conducted in 10 randomly selected public health centers (HCs) in Addis Ababa and baseline data collected on BEmONC status from January to March 2013. Retrospective routine record reviews and facility observations were done in 29 HCs in 2008 and in10 HCs in 2013. Twenty-five providers in 2008 and 24 in 2013 participated in BEmONC knowledge and skills assessment. All the data were collected using standard tools. Descriptive statistics and t-tests were used.ResultsIn 2013, all the surveyed HCs had continuous water supply, reliable access to telephone, logbooks & phartograph. Fifty precent of the HCs in 2013 and 34% in 2008 had access to 24 hours ambulance services. The ratio of midwives to 100 expected births were 0.26 in 2008 and 10.3 in 2013. In 2008, 67% of the HCs had a formal fee waiver system while all the surveyed HCs had it in 2013. HCs reporting a consistent supply of uterotonic drugs were 85% in 2008 and 100% in 2013. The majority of the providers who participated in both surveys reported to have insufficient knowledge in diagnosing postpartum haemorrhage (PPH) and birth asphyxia as well as poor skills in neonatal resuscitation. Comparing with the 2008 survey, no significant improvements were observed in providers’ knowledge and competence in 2013 on PPH management and essential newborn care (p > 0.05).ConclusionThere are advances in infrastructure, medical supplies and personnel for EmONC provision, yet poor providers’ competences have persisted contributing to the quality gaps on BEmONC in Addis Ababa. Considering short-term in-service trainings using novel approaches for ensuring desired competences for large number of providers in short time period is imperative.

Exploring inequities in skilled care at birth among migrant population in a metropolitan city Addis Ababa, Ethiopia; a qualitative study

IntroductionEthiopia records high levels of inequity in skilled birth care (SBC), where the gaps are much wider among urban migrant women. An intervention project has been conducted in Addis Ababa, intending to improve quality and to ensure equitable access to maternal and newborn care services. As part of the project, this study explored the inequities in maternal health care among migrant women in Addis Ababa, Ethiopia.MethodsA qualitative community based study was conducted from April to May 2014 among 45 purposefully selected internal migrant women. Eleven women who give birth at home and eight who gave birth at health facility in the last year preceding the study participated in in-depth interviews. Four primiparas´ young women, 18 women who have children and four grandmothers participated in focus group discussions. Guides were used for data collection. Using framework and content analysis three themes and four sub-themes emerged.ResultsAccording to the informants, patterns of service utilization varied widely. Antenatal care and infant immunization were fairly equally accessed across the different age groups of informants in their most recent birth irrespective of where they gave birth, yet obvious access gaps were reported in SBC and postpartum care. There were missed opportunities to postpartum care. Only few women had received postpartum care despite, some of the women delivering in the health facility and many visiting the health facilities for infant immunization. The four emerged sub-themes reportedly influencing access and utilization of SBC were social influences, physical access to health facility, risk perceptions and perceived quality of care and disrespect. Of these social, structural and health system factors, informants presented experiences of disrespectful care as a powerful deterrent to SBC.ConclusionsMigrant women constitute disadvantaged communities in Addis Ababa and have unequal access to SBC and postpartum care. This happens in the backdrop of fairly equitable access to antenatal care, infant immunization, universal health coverage and free access to maternal and newborn care. Addressing the underlying determinants for the inequities and bridging the quality gaps in maternal and newborn services with due emphasis on respectful care for migrant women need tailored intervention and prioritization.

Comparing HIV prevalence estimates from prevention of mother-to-child HIV transmission programme and the antenatal HIV surveillance in Addis Ababa

BackgroundIn the absence of reliable data, antenatal HIV surveillance has been used to monitor the HIV epidemic since the late 1980s. Currently, routine data from Prevention of Mother-to-child HIV transmission (PMTCT) programmes are increasingly available. Evaluating whether the PMTCT programme reports provide comparable HIV prevalence estimates with the antenatal surveillance reports is important. In this study, we compared HIV prevalence estimates from routine PMTCT programme and antenatal surveillance in Addis Ababa with the aim to come up with evidence based recommendation.MethodsSummary data were collected from PMTCT programmes and antenatal surveillance reports within the catchment of Addis Ababa. The PMTCT programme data were obtained from routine monthly reports from 2004 to 2009 and from published antenatal HIV surveillance reports from 2003 to 2009. Data were analysed using descriptive statistics.ResultsIn Addis Ababa, PMTCT sites had increased from six in 2004 to 54 in 2009. The site expansion was accompanied by an increased number of women testing. There were marked increases in the rate of HIV testing following the introduction of routine opt-out HIV testing approach. Paralleling these increases, the HIV prevalence showed a steady decline from 10.0% in 2004 to 4.5% in 2009. There were five antenatal surveillance sites from 2003 to 2007 in Addis Ababa and they increased to seven by 2009. Four rounds of surveillance data from five sites showed a declining trend in HIV prevalence over the years. The overall antenatal surveillance data also showed that the HIV prevalence among antenatal attendees had declined from 12.4% in 2003 to 5.5% in 2009. The HIV prevalence estimates from PMTCT programme were 6.2% and 4.5% and from antenatal surveillance 6.1 and 5.5% in 2008 and 2009 respectively.ConclusionsThere were consistent HIV prevalence estimates from PMTCT programme and from antenatal surveillance reports. Both data sources showed a marked decline in HIV prevalence among antenatal care attendees in Addis Ababa. This study concludes that the routine data from the PMTCT programmes in Addis Ababa provides comparable HIV prevalence estimates with antenatal HIV surveillance data and could be used for monitoring trends.