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Factors Influencing Loss to Follow-up among Human Immunodeficiency Virus Exposed Infants in the Early Infant Diagnosis Program in Phalombe, Malawi.

ABSTRACT: The efforts to prevent mother to child transmission of HIV in Malawi are impeded by the loss to follow-up of HIV-exposed infants (HEI) in care. Early infant diagnosis (EID) of HEI and linkage to care reduces morbidity and mortality. There has been limited attention to infants who are lost to follow up despite their mothers being compliant to the PMTCT program. This study explored factors that influence loss-to-follow up among HEI in the EID program whose mothers were retained in care for up to 24 months in Phalombe district, Malawi. We conducted a descriptive phenomenological qualitative study from May 2017 to July 2018. We purposively conducted 18 in-depth interviews among HIV positive mothers whose HEI were enrolled in the follow-up program and 7 key informant interviews among healthcare workers (HCW). All interviews were digitally recorded, transcribed, and translated verbatim. Data were analyzed manually using a thematic step-by-step approach. Results showed that retention in care is facilitated by aspirations to have a healthy infant and linkage to a nearer facility to a mother's place of residency. The barriers to retention were non-disclosure of HIV status, inadequate resources, and support, suboptimal guidelines for, a lack of privacy, and unsynchronized hospital visits between a mother and her baby. The study has shown that successful implementation of EID services requires concerted efforts from various contextualized stakeholders whilst focusing on family-centered care. To maximize retention in EID and innovative ways of reaching mothers and babies through flexible guidelines are urgently needed.

SUBMITTER: Nkhonjera J

PROVIDER: S-EPMC7995308 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:INTRODUCTION:Complete follow-up of human immunodeficiency virus (HIV)-exposed infants (HEI) is crucial for a successful prevention of mother-to-child HIV transmission. This study analyzed the HEI follow-up and factors associated with loss to follow-up (LTFU) in southern Mozambique. METHODS:This retrospective cohort study used the data of HEI enrolled between June 2017 and June 2018, followed-up for 18 months. The outcomes were the proportion of infants with completed follow-up and a definitive diagnosis, and the presence of clinical events. Kaplan-Meier survival analysis was used to calculate the cumulative probability of LTFU and of clinical events. Factors associated with LTFU and clinical events were analyzed using Cox regression to calculate the hazard ratio (HR) and adjusted HR (AHR), with a 95% confidence interval (CI) and a significance cutoff of p<0.05. RESULTS:1413 infants were enrolled (49% males) at a median age of 32 days (IQR 31-41); the median follow-up time was 12 months (IQR 8.2-14.2); 1129 (80%) completed follow-up and had a definitive diagnosis, 58 (4%) were HIV-positive, 225 (16%) were LTFU; 266 (19%) presented a clinical event. Factors associated with LTFU were: age >2 months at entry (AHR, 1.58; 95% CI, 1.12-2.23), non-exclusive breastfeeding (AHR, 1.44; 95% CI, 1.01-2.06), poor cotrimoxazole adherence (AHR, 3.42; 95% CI, 1.59-7.35), and clinical events (AHR, 0.51; 95% CI, 0.34-0.77). Factors associated with clinical events were: malnutrition (AHR, 10.06; 95% CI, 5.92-17.09), non-exclusive breastfeeding (AHR, 1.98; 95% CI, 1.34-2.93), no nevirapine prophylaxis (AHR, 1.67; 95% CI, 1.18-2.36), and poor cotrimoxazole adherence (AHR, 2.62; 95% CI, 1.10-6.22). CONCLUSION:The high rate of HEI LTFU, associated with delayed linkage to postnatal care, poor prophylaxis adherence, non-exclusive breastfeeding, indicates the need to design a differentiated service delivery model that is tailored to the mothers' and infants' specific needs.

Project description:BackgroundSince 2001 the South African guidelines to improve child health and prevent vertical HIV transmission recommended frequent infant follow-up with HIV testing at 18?months postpartum. We sought to understand non-attendance at scheduled follow-up study visits up to 18?months, and for the 18-month infant HIV test amongst a nationally representative sample of HIV exposed uninfected (HEU) infants from a high HIV-prevalence African setting.MethodsSecondary analysis of data drawn from a nationally representative observational cohort study (conducted during October 2012 to September 2014) of HEU infants and their primary caregivers was undertaken. Participants were eligible (N?=?2650) if they were 4-8?weeks old and HEU at enrolment. All enrolled infants were followed up every 3?months up to 18?months. Each follow-up visit was scheduled to coincide with each child's routine health visit, where possible. The denominator at each time point comprised HEU infants who were alive and HIV-free at the previous visit. We assessed baseline maternal and early HIV care characteristics associated with the frequency of 'Missed visits' (MV-frequency), using a negative binomial regression model adjusting for the follow-up time in the study, and associated with missed visits at 18?months (18-month MV) using a logistic regression model.ResultsThe proportion of eligible infants with MV was lowest at 3?months (32.7%) and 18?months (31.0%) and highest at 12?months (37.6%). HIV-positive mothers not on triple antiretroviral therapy (ART) by 6-weeks postpartum had a significantly increased occurrence rate of 'MV-frequency' (adjusted incidence rate ratio, 1.2 (95% confidence interval (CI), 1.1-1.4), p?<?0.0001). Compared to those mothers with ART, these mothers also increased the risk of '18-month-MV' (adjusted odds ratio, 1.3 (CI, 1.1-1.6), p?=?0.006). Unknown infant nevirapine-intake status increased the rate of 'MV-frequency' (p?=?0.02). Mothers >?24?years had a significantly reduced rate of 'MV-frequency' (p???0.01) and risk of '18-month-MV' (p?<?0.01) compared to younger women. Shorter travel time to health facility lowered the occurrence of 'MV-frequency' (p???0.004).ConclusionLate initiation of maternal ART and infant prophylaxis under the Option- A policy and extended travel time to clinics (measured at 6?weeks postpartum), contributed to higher postnatal MV rates. Mothers older than 24?years had lower MV rates. Targeted interventions may be needed during the current PMTCT Option B+ (lifelong ART to pregnant and lactating women at HIV diagnosis) to circumvent these risk factors and reduce missed visits during HIV-care.

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Factors Influencing Loss to Follow-up among Human Immunodeficiency Virus Exposed Infants in the Early Infant Diagnosis Program in Phalombe, Malawi.

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