RESUMO
Background: The prevention of mother-to-child transmission (PMTCT) is considered one of the most successful HIV prevention strategies in detecting and reducing HIV acquisition in utero or at birth. It is anticipated that with the increasing growth of digital technologies mobile phones can be utilized to enhance PMTCT services by improving provider-client interactions, expanding access to counseling services, and assisting in counteracting social and structural barriers to uptake of PMTCT services. Understanding the subjective experiences of women accessing PMTCT services in different settings has the potential to inform the development and promotion of such methods. This paper explores the perspectives of HIV-positive pregnant women attending maternal and neonatal clinic services in Kisumu, Kenya. Methods: Data are reported from in-depth interviews with women, following a longitudinal study investigating the impact of a structured, counselor-delivered, mobile phone counseling intervention to promote retention in care and adherence to ARV prophylaxis/treatment, for HIV-positive pregnant women. Thematic content analysis was conducted. Results: Discussions indicated that mobile-phone counseling provided useful health-related information, enhanced agency, and assisted mothers access critical PMTCT services across the cascade of care. Similarly, mobile-phone counseling offered personalized one-to-one contact with trained health providers including facilitating discussion of personal issues that likely affect access to services. Findings also identified barriers to the uptake of services, including a lack of partner support, poor health, poverty, facility-related factors, and provider attitudes. Discussion: Overall, findings show that mobile-phone counseling is feasible, acceptable, and can enhance access to PMTCT services by overcoming some of the individual and facility-level barriers. Although mobile-phone counseling has not been routinized in most health facilities, future work is needed to assess whether mobile-phone counseling can be scaled-up to aid in the effective use of HIV and PMTCT services, as well as improving other related outcomes for mother and child dyad.
RESUMO
BACKGROUND: We evaluated the effectiveness of a cell phone counseling intervention to promote retention in care and HIV testing of infants among women with HIV accessing prevention of mother-to-child services in Kisumu, Kenya. METHODS: Between May 2013 and September 2015, we recruited 404 pregnant women with HIV who were between 14 and 36 weeks of gestation and randomly assigned them to the intervention (n=207) or control arm (n=197). Retention was assessed at delivery and at 6 and 14 weeks postpartum. We also measured uptake of infant HIV testing. The intervention comprised a fixed protocol of counselor-delivered phone calls to provide one-to-one need-based support. The number of calls made varied depending on when participants presented for antenatal care services; the maximum number was 42. The control group received routine care. We evaluated retention at 3 time points using the complementary log-log regression model taking into account factors associated with retention and loss to follow-up time. We calculated the incidence rate for HIV transmission among infants and used binary logistic regression to identify predictors of HIV infection among infants. RESULTS: Participants attended on average 63% of the required number of counseling calls during the study period. Retention was higher in the intervention arm than the control arm at delivery (95.2% vs. 77.7%, respectively); 6 weeks postpartum (93.9% vs. 72.9%, respectively); and 14 weeks postpartum (83.3% vs. 66.5%, respectively) (P<.001). The counseling intervention (hazard ratio [HR]=0.29; 95% confidence interval [CI]=0.12, 0.69) and positive health perceptions (HR=0.99; 95% CI=0.98, 1.00) were associated with lower hazards of being lost to follow-up. HIV testing of infants was higher in the intervention than control arm (93% vs. 68%, respectively; P<.001). In total, 9 of 308 (2.9%) infants tested positive for HIV infection (incidence rate=0.39 infections/100 infant-weeks). Medication Possession Ratio (MPR) >90%, used to assess adherence to ART, was associated with lower odds of a positive HIV test among infants (adjusted odds ratio=0.20; 95% CI=0.04, 0.99). Attendance at antenatal and postnatal care visits was higher among participants in the intervention arm than the control arm. CONCLUSIONS: The one-on-one tailored counseling delivered via cell phone was effective in retaining mothers with HIV infection in care and promoting uptake of infant HIV testing and antenatal and postnatal care services. Phone counseling offers a practical approach to reach and retain pregnant women with HIV infection and postpartum mothers in care, but greater emphasis on collection of medications and adherence is required.