Effectiveness of National
Program for the Prevention of
Mother-to-Child Transmission
(PMTCT) of HIV in Rwanda
Report – May 2010
Research Consortium:
Treatment and Research AIDS Center (TRACPlus)
National University of Rwanda-School of Public Health (NUR-SPH)
National Reference Laboratory (NRL)
United Nations Children’s Fund (UNICEF)
Funded by:
Global Funds to fight AIDS, Tuberculosis and Malaria
United Nations Children’s Fund (UNICEF)
1
Table of content
LIST OF TABLES ........................................................................................................................................ 5
LIST OF FIGURES ...................................................................................................................................... 6
ACKNOWLEDGEMENT ............................................................................................................................. 7
ACRONYMS ............................................................................................................................................. 8
EXECUTIVE SUMMARY ............................................................................................................................ 9
I. INTRODUCTION, SIGNIFICANCE AND OBJECTIVES OF THE STUDY ..................................................... 11
II. METHODS .......................................................................................................................................... 15
II.1 Quantitative methodological approaches .................................................................................. 15
II.1.1. Study design ........................................................................................................................ 15
II.1.2. Sampling procedures .......................................................................................................... 15
II.1.3. Sample size estimation ....................................................................................................... 15
II.1.4. Questionnaires .................................................................................................................... 16
II.1.5. HIV testing and Anthropometric measurement amongst children .................................... 17
II.2 Qualitative methodological approaches ..................................................................................... 18
II.2.1 Sample and study participants ............................................................................................. 18
II.2.2 Training of facilitators and piloting of guides ...................................................................... 18
II.2.3 Data collection techniques................................................................................................... 19
II.2.4 Data collection procedures .................................................................................................. 19
II.3 Ethical procedures ...................................................................................................................... 19
II.4 Data management and analysis .................................................................................................. 20
II.4.1 Quantitative data entry processing and analysis ................................................................. 20
II.4.2 Qualitative data processing and analysis ............................................................................. 23
III. RESULTS............................................................................................................................................ 25
III.1. Description of survey participants ............................................................................................ 25
III.1.1 Survey participants ............................................................................................................. 25
III.1.2. Mother’s ARV uptake ......................................................................................................... 26
2
III.1.3. Characteristics of respondents and their households ....................................................... 27
III.1.4 Level of participation in PMTCT program .......................................................................... 29
III.2. Mortality among children 9-24-month old ............................................................................... 30
III.2.1. Mortality rate among children ........................................................................................... 30
III.2.2. Child survival by 9-24 months ............................................................................................ 31
III.2.3. Factor associated with mortality in children 9-24-month old ........................................... 34
III.3. HIV infection among children born to HIV positive mothers.................................................... 37
III.3.1. Laboratory testing results .................................................................................................. 37
III.3.2. HIV test quality control results .......................................................................................... 38
III.3.3. Prevalence of HIV among children 9-24-month old .......................................................... 38
III.3.4. HIV infection among children 9-24-month old and PMTCT program indicators ............... 40
III.3.5. Child HIV infection and/or death by 9 months of age and PMTCT indicators ................... 43
III.4. Nutrition status among children 9-24-month old ..................................................................... 45
III.4.1. Level of nutrition among children...................................................................................... 45
III.4.2. Nutrition status by level of participation in PMTCT program ............................................ 47
III.4.3. Factor associated with child nutritional status .................................................................. 49
III.5. Use of reproductive health services by mother’s HIV status .................................................... 50
III.5.1. Facility based versus home delivery .................................................................................. 50
III.5.2. Desire of future pregnancy ................................................................................................ 51
III.6. Results from the qualitative survey .......................................................................................... 52
III.6.1 Problems facing PMTCT clients ........................................................................................... 52
III.6.2 PMTCT users’ perceptions of services provided ................................................................. 54
III.6.3 Critics of PMTCT services and suggestions for quality improvement ................................ 57
III.6.4 Barriers to PMTCT use ........................................................................................................ 58
II.6.5 Community attitude towards PMTCT program ................................................................... 61
IV. CONCLUSION AND RECOMMENDATIONS ....................................................................................... 64
IV.1 Conclusion.................................................................................................................................. 64
3
IV. 2 Recommendations .................................................................................................................... 66
V. REFERENCES ...................................................................................................................................... 67
4
LIST OF TABLES
Table 1: Participants in focus group discussion ......................................................................................... 18
Table 2: Definition of outcome measures................................................................................................... 20
Table 3: Individual and household variables used in the mother’s survey ............................................... 21
Table 4: Adherence to PMTCT protocol: measures taken by HIV + mothers to prevent HIV
transmission from mother to child ............................................................................................................. 22
Table 5: Socio-demographic characteristics of the respondents by HIV status......................................... 28
Table 6: Household characteristics of respondents by HIV status ............................................................ 29
Table 7: Levels of participation in PMTCT program by ANC visits ............................................................ 30
Table 8: Mortality rates among children ................................................................................................... 31
Table 9: Child mortality by respondent and household characteristics .................................................... 35
Table 10: Cox proportional hazard regression models of time to death and factor associated with
variability in time to death among children................................................................................................ 36
Table 11: Results of laboratory testing ..................................................................................................... 37
Table 12: Child HIV infection and PMTCT program indicators .................................................................. 40
Table 13: Child HIV infection and demographic or socioeconomic characteristics of their mothers........ 41
Table
14:
Results
of
logistic
model
of
infection….……………………………………………………………………….Error! Bookmark not defined.
infant
HIV
Table 15: HIV infection and/or death among children .............................................................................. 43
Table 16: Results of logistic model of infant HIV infection and/or death ................................................. 44
Table 17: Association between adherence to PMTCT factors and infant's nutritional status................... 48
Table 18: Association between infant feeding modes and infant's nutritional status .............................. 49
Table 19: Predictors factor of infant's nutritional status among infants born to HIV+ mothers ............... 50
Table 20: Odds of delivering at a health facility and mother’s HIV treatment during pregnancy,
adjusting for other covariates ..................................................................................................................... 50
Table 21: Desire for future pregnancy and mother’s serological status .................................................... 51
5
LIST OF FIGURES
Figure 2: Mother-child survey participants................................................................................................ 25
Figure 3: ARV and/or OI uptake among surveyed HIV positive mothers ................................................... 27
Figure 4: Child survival by mother’s serological status .............................................................................. 32
Figure 5: Child survival by the number of ANC visits ................................................................................. 33
Figure 6: Child survival by place of birth ................................................................................................... 34
Figure 7: Results of quality control of HIV testing .................................................................................... 38
Figure 8: Distribution of anthropometric indices (ZHA) among surveyed children ................................... 45
Figure 9: Distribution of anthropometric indices (ZWH) among surveyed children................................. 46
Figure 10: Distribution of anthropometric indices (ZWA) among surveyed children ............................... 46
Figure 11: Nutritional Status by infant age ............................................................................................... 47
6
ACKNOWLEDGEMENT
This study has been made possible through a consortium of several partners: The School of
Public Health of National University of Rwanda (NURSPH), Center for Treatment and
Research on AIDS, Malaria, Tuberculosis and Other Epidemics (TRACPlus), National
Reference Laboratory of Rwanda (NRL), and United Nations Children's Fund (UNICEF).
This study was generously funded by the Global Funds to fight AIDS Tuberculosis and
Malaria; and UNICEF.
The Principal Investigators for this study, namely Alexandre Lyambabaje, PhD, Elvanie
Munyana, MPH, Jean de Dieu Bizimana, PhD and Jeanine Condo, PhD contributed
significantly to the development of the research protocol, survey instruments, overall survey
design, technical and field support, and report writing and dissemination of findings.
The qualitative component of this research was led by Isaac Ntahobakulira, MPH, and
Laetitia Nyirazinyoye, MPH, PhD, both faculty members at NURSPH. They were actively
involved in developing the Focus Group Discussion (FGD) guides, leading related data
collection, analysis and report writing.
TRACPlus, the institution implementing the PMTCT program in Rwanda, provided
invaluable insight and support during the study implementation. Dr. Anita Asiimwe, former
Director of TRACPlus and current Executive Secretary of CNLS provided the research team
with valuable guidance to research design and appropriate domain of interest. Dedicated
TRACPlus staff including Drs. Antoine Rwego Gasasira, Placidie Mugwaneza, and Nadine
Umutoni Shema participated actively in several meetings that discussed the survey
implementation as well in interpretation of the findings.
The contribution of the National Reference Laboratory of Rwanda was essential in ensuring
the highest quality standards in HIV testing amongst children involved in this study,
dedicating key staff, time, and effort. Dr Odette Mukabayire, the Director of NRL was
involved in early stages of protocol development while Mr. Jean Claude Uwimbabazi, a lab
technician expert actively participated in training lab technicians for blood testing for HIV,
supervised the blood sample collection, and performed laboratory analysis. Furthermore, the
NRL provided lab equipments and materials for HIV testing for this study..
In addition to providing funds for this study, UNICEF has ensured the highest quality
standards in the survey implementation by providing technical support throughout its
implementation. Dr Jane Muita, Mrs. Ndoli Cecile and Mrs. Daoussi Radia participated in
developing the survey protocol. A PMTCT working group that operates under UNICEF
reviewed a draft survey instrument in great detail, provided modifications to ensure research
question relevance, and appropriate domains of interest. The contribution of Dr. Landry
Tsague in the study validation and dissemination is greatly appreciated.
Fieldwork was accomplished in partnership with a number of professionals from NURSPH.
Dr. Etienne Rugigana supervised the data collection for the quantitative survey. Mr. Jean
D’Amour Habagusenga served as Field Coordinator and six supervisors lent invaluable
oversight and support to the field team. Mrs. Peace Kinani provided logistical support. A
team of thirty interviewers and twelve lab technicians worked tirelessly to conduct the
surveys with mothers, PMTCT providers, and to perform with great care blood sample
collection among children. Mrs. Lucie Musabyimana and Nathalie K. Mulindahabi led the
team that worked on the data entry and provided significant support with data management.
7
ACRONYMS
AIDS:
Acquired Immunodeficiency Syndrome
ARV:
Anti retroviral drugs
AZT:
Azido Thymidine (Zidovidine)
DBS:
Dried Blood Spot
DHS:
Demographic Health Survey
ELISA:
Enzym Linked Immuno absorbent Assay
FGD:
Focus Group Discussion
FP:
Family Planning
GFATM:
Global Fund
HC:
Health Center
HIV:
Human Immunodeficiency Virus
NRL:
National Reference Laboratory
NVP:
Nevirapine
PCR:
Polymerase Chain Reaction
PMTCT:
Prevention from Mother to Child transmission of HIV / AIDS
PLWHA:
People living with HIV/AIDS
TRAC:
Treatment and Research AIDS Center
UNAIDS:
United Nations Joint Program on HIV/AIDS
UNICEF:
United Nations Children's Fund
VCT:
Voluntary Counseling and Testing
8
EXECUTIVE SUMMARY
Mother-to-Child Transmission (MTCT) of HIV remains the major source of pediatric HIV infection. In 2007,
370,000 children under 15 years became infected and nearly 90% of them lived in Sub-Saharan Africa. Each
year in Rwanda, about 40,000 to 50,000 babies are born to HIV positive mothers. Without interventions to
prevent mother-to-child transmission of HIV, about 35% of children born to HIV infected (HIV+) mothers will
become infected with HIV by 24 months of age.
Rwanda launched the national program for the Prevention of Mother-to-Child HIV Transmission (PMTCT) in
2001 aiming at reducing by 50% the MTCT rate by 2010. Strategic approaches to PMTCT include four prongs:
primary prevention of HIV infection; prevention of unintended pregnancies among HIV-infected women;
prevention of HIV transmission from HIV-infected women to their infants; and the provision of care and
support to HIV-infected women and their infants and families. In September 2005, the PMTCT program
introduced multidrug ARV regimens (HAART for eligible women; and dual prophylaxis for non eligible
women and all exposed infants) to gradually replace single-dose nevirapine. PMTCT services are integrated
within antenatal care visits, maternity and baby care, and family planning services. However, its effectiveness in
Rwanda has not yet been documented. Understanding the determinants of MTCT of HIV in routine program
implementation is critical for designing appropriate policies and strategies for effective PMTCT programming.
We report on the findings of an evaluation of the effectiveness of the Rwanda National PMTCT Program,
primarily measured by HIV-free survival at 9 months post-delivery.
We used both the quantitative and qualitative methodological approaches. We conducted a national crosssectional household survey among mother and children who were expected to be 9-24 months at the time of the
survey. In a stratified, two-stage cluster sampling design, we successively selected health facilities and HIV
infected and HIV non infected mothers who expected a child from March 2007-June 2008 in ANC registries. At
household level, mothers were interviewed with their consent, living index child blood was collected using
finger-prick and HIV test was performed on three parallel rapid tests; confirmation of HIV+ for less than 18
months old and undetermined results was done by PCR. Several variables including number of ANC visits,
ARVs taken by either mother or child, place of delivery and feeding options were measured.
A total of 3020 mother-child pairs were surveyed. Among 2935 children (97%) who were alive, 2852 (97%)
were tested for HIV including 1341(47%) born to HIV+ mothers. HIV prevalence among living exposed
children was about 3.96% (95% CI: 3.26-4.80). Children born to HIV+ women on triple therapy were less likely
to be HIV+ than children born to HIV+ mothers who did not take any ARV during pregnancy(OR: 0.35, 95%
CI: 0.15-0.81).
24 out of 1431 children born to HIV+ mothers (1.65% [95%CI:0.99%-2.30%]) died before the age of 6 months
compared to 18 out of 1547 born to HIV non-infected mothers (1.15% [95%CI:0.62%-1.68%]). No significant
difference in risk of dying was observed by the 6 months of age between the two groups.
However, by the age of 9 months, mortality rates were 2.75% (95%CI: 1.91%-3.59%) vs. 1.15%
(96%CI:0.62%-1.68%) for children born to HIV infected and HIV non-infected mothers respectively. By the
9
age of 9 months, hazard of death among children born to HIV infected mothers was 3 times higher (adjusted
hazard ratio: 3.26; [95% CI: 1.37-7.77]) compared with children born to HIV negative mothers.
Again, infant's HIV status is one of the main predictor of malnutrition even after controlling for mothers HIV
status, ARVs treatment, place of delivery and number of ANC (OR=3, 95% CI [1.2 , 5.7]). 48% of 2642 infants
were stunted, 8% wasted and 15% had a low weight for their age. Moreover, stunting was high among HIV
infected children (73%) compared to non-infected children (47%).
In spite of sensitization and intensive campaign for VCT and PMTCT, barriers to access and use of PMTCT
related services persist. Participants to focus group discussions across the country reported several barriers that
preclude both women and children from achieving an effective uptake of PMTCT program. Perceived barriers
include individual factors such as ignorance of benefits from ANC, fear of test results and discrimination, and
extra marital pregnancies. External barriers are related to lack of partner support, isolation from the family,
misbehavior of health care providers and non affordable feeding items for babies.
10
I. INTRODUCTION, SIGNIFICANCE AND OBJECTIVES OF THE STUDY
I.1 Introduction
The HIV epidemic continues to be one of the major global health challenges facing the world today. According
to the 2009 UNAIDS Annual Report, an estimated 33.4 million people are living with HIV/AIDS worldwide,
with 2.1 million children infected. In sub-Saharan Africa alone, about 22.4 million people (67% of HIV
infections worldwide)are infected, of which 60% are women, thereby jeopardizing the health of future
generations. According to the same report, 71% of the new HIV infections and 72% of the estimated number of
deaths due to AIDS in the world occurred in Sub Saharan Africa. Additionally, the number of HIV-infected
children younger than 15 years increased from 1.6 million in 2001 to 2.0 million in 2007, with 90% of these
children living in Sub-Saharan Africa (UNAIDS, 2007). Every day, more than 8000 people die of AIDS
globally, mainly because of a lack of access to prevention and treatment services. In highly affected countries,
entire families and communities have been decimated by HIV and AIDS which in turn threaten the socioeconomic fabric of these countries.
Progress has been made in the introduction and scaling up of prevention of mother to child HIV transmission
programs (PMTCT), which allows HIV positive women to have access to services that can improve their health
and prevent HIV transmission to their infants. The United Nations strategic approach to PMTCT is a four
prongs strategy which includes: primary prevention of HIV infection; prevention of unintended pregnancies
among HIV-infected women; prevention of HIV transmission from HIV-infected women to their infants; and
the provision of care and support to HIV-infected women and their infants and families.
While the rate of vertical transmission from mother to child has been reduced to below 2% in industrialized
countries through adequate prophylaxis, elective c-section and replacement feeding, pediatric AIDS remains an
uncontrolled epidemic in developing countries (5), even though the number of new infections in infants has
decreased from 460,000 to 420,000. HIV transmission to infant can occur in utero (8-10%), during peri-partum
period (10-15 %), and post-partum through breastfeeding (15-20%). Without any prevention, vertical
transmission rates vary from 15% to 25% in industrialized countries; and from 25% to 45% in developing
countries (UNAIDS, 1999).
While progress has been made in terms of reducing HIV infections in children, a valid measure of PMTCT
program effectiveness is lacking. In 2005, only 2% of exposed infants globally received an HIV test in their first
18 months of life, which complicates the evaluation of PMTCT effectiveness (6).
I.2 Background literature
The 2005 Rwanda Demographic Health Survey provides important contextual data for the PMTCT program as
it shows the reproductive health challenges as a backdrop. For instance, nationwide, a whopping 70% births
occurred at home, which represents a challenge for a PMTCT program that is mainly clinic-based. This
proportion of home births exceeds 80% among women with no education, among those who did not attend
11
prenatal care visits, and among those living in a household in the poorest quintile. In 61% of cases, women did
not receive assistance of trained personnel while giving birth; 43% were assisted by traditional, untrained
midwives, and 17% gave birth with no assistance. These unassisted births are more frequent in rural areas than
in urban areas (19 %versus 9%). Moreover, among women who did not give birth in a health facility, nearly all
(95%) failed to benefit from any postnatal care during the two days following birth, let alone treatment or care
for HIV infection.
About 15% of infants born at home were brought by a family member to receive the ARV dose. More than 66%
of these cases did not return within the recommended 72 hour time frame (1). However, intermediate DHS
(2007) shows a slight increase on assisted delivery by a health professional that increases from 39% to 52%.
Also according to the 2005 DHS, HIV prevalence among women was estimated at 8.6% and 2.6% in urban and
rural areas respectively. In 1999, Rwanda launched the first PMTCT pilot site at Kicukiro Health Center. Since
then, there was a continuous scale up of the program and it is integrated within antenatal care visits, maternity,
baby care, and family planning services. At the national level, many Health centers (HC) have integrated
prevention, care and treatment services. In 2008, there were 341 HC offering PMTCT services, 365 HC offering
VCT services, and 217 HC offering ARV medication. The aim of Rwandan PMTCT is to reduce Mother to
child HIV transmission up to 2% by 2012 (National Strategic Plan to Fight Against AIDS 2009-2012). The
focus is on four main strategies: prevention of HIV infection among women of childbearing age; prevention of
unwanted pregnancy among HIV-positive women; prevention of MTCT during pregnancy, labor and delivery,
and breastfeeding and finally the provision of care and support to HIV-infected women and their infants and
families.
In 2008, according to PMTCT program routine data, the acceptance rate of HIV testing among pregnant women
attending ANC was high (97%), with an HIV prevalence rate of 2.98 %. In 2005, National PMTCT ARV
prophylaxis guidelines was upgraded from single dose Nevirapine (sd-NVP) to more efficacious regimens in
order to reduce the risk of MTCT. The PMTCT ARV protocol includes triple-therapy for eligible women; and
for non-eligible women, a combination of Zidovudine (2x 300 mg AZT daily) starting at 28-week gestation until
labor plus sd-NVP tablet at the onset of labor. After delivery, AZT+3TC is added (1 tablet twice daily for 7
days). For non-eligible women who are tested HIV positive after 34 weeks of gestation, short course tripletherapy is also recommended until delivery, plus AZT+3TC (1 tablet twice daily for 7 days) after delivery.
Infant receives sd-NVP syrup (2mg/kg) within 72 hours of birth coupled with an AZT syrup twice daily during
one month.
The national PMTCT program tested 1,109,068 pregnant women between 2001 and 2008 and reached coverage
of 75 % by the end of 2008. The HIV testing acceptance rate is high (97%) among pregnant women and their
partners (78%)1 . In 2008, out of 8,790 pregnant women who tested HIV positive, 7,151 (82%) among them
received ARV prophylaxis, including 1217 (15 %) women initiated on triple therapy. Health facility delivery
among HIV+ pregnant women was high (76%) in 2008 and 93% of them received ARV prophylaxis. Among
1
2008 Annual Report (Treatment and Research on AIDS Center)
12
infant born to HIV+ mothers, 91% received ARV prophylaxis at birth. In the post partum, about 70% of HIV+
women adopted a contraceptive method.
All women who attended PMTCT services received the single dose NVP to be ingested after labor onset, but
only 61% of women ingested it before delivery. Reasons for not ingesting the NVP tablet include forgetfulness
(30%), fear of taking the medicine (30%), rapid progress of labor (20%), and lastly, because their partner was
present (20%) (11) . Qualitative results show that family planning is hampered by a common practice where HC
recommend the approval of partners as a pre-condition for a woman to receive a contraceptive method.
To minimize the vertical transmission of HIV from the mother to her infant, medical treatment is supported by
safer delivery and safer replacement feeding or exclusive breastfeeding up to 6 months. However, the
effectiveness of the national PMTCT program in Rwanda has not yet been studied and documented.
I.3 Significance of the study
Until today, few studies in Rwanda have assessed the effectiveness of the PMTCT program at the national level.
Although, there are some studies that have evaluated specific aspects of the program, data collection has been
facility-based. However, it is known that monitoring systems do not always adequately capture the reality of
PMTCT programs and tend to either under or over-report data (9). More importantly, facility-based reporting
fails to capture home deliveries with or without a skilled birth attendant. Although from health facility based
report at TRAC PLUS, the prevalence rate of HIV transmission from mother to child at the program level is
estimated at 6.9% (TRACPlus /HAS annual report,2008), this figure does not reflect the prevalence rate at
national level.
There is no clear consensus on how to better evaluate PMTCT programs due to the very nature of these
programs; the mother-infant pair goes through a “cascade” of interventions necessary to ensure a reduced
likelihood of HIV transmission to infant: HIV testing, return and accept her results, ARV prophylaxis for
mother and infant, safe delivery, infant feeding method, follow up of mother (care and treatment, family
planning) and infant (cotrimoxazole prophylaxis, infant HIV testing, clinical and monitoring) (3,5). The
1effectiveness of the programs is compromised if there is a low coverage at any stage of the cascade. The few
studies that have attempted to evaluate such programs show the logistical, managerial, and technical challenges
in delivering effective preventive services (2, 9).
An evaluation at the population level would enable data collection that could not be generated through the
routine process indicators, namely client satisfaction, and their impact on outcomes of interest such as HIV
infection status of children, child mortality, as well as the social consequences of HIV testing and replacement
feeding if it has taken place. Due to loss to follow up, these data are lacking on a large proportion of exposed
and HIV-infected infants (7).
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I.4 Purpose of the study
The purpose of the current study was to investigate the effectiveness of the national PMTCT program in
Rwanda eight years after its inception. The effectiveness of PMTCT program was primary measured by HIVfree survival by the age of 9 months among children born to HIV positive mothers. HIV-free survival amongst
these children is estimated from the risk of acquiring HIV infection and/or dying by the age of 9 months.
Child under nutrition is highly prevalent in low-income and middle-income countries, resulting in substantial
increases in mortality and overall disease burden. Moreover HIV/AIDS is believed to worsen the existing
precarious nutritional status. We therefore evaluate the nutritional status among children born to HIV infected
women. The overall prevalence of stunting, wasting and underweight amongst children born to HIV infected
mothers is estimated first and then evaluated in terms of childhood HIV serological status and key PMTCT
program indicators.
We also report on desire of future pregnancy and unmet needs for family planning services among HIV infected
women in comparison to HIV negative women. Belief, perception, and attitude of the community towards
PMTCT program are also explored.
I.5 Specific Objectives

To estimate the risk of dying by 9 months of age amongst born to HIV infected mothers

To estimate the prevalence of HIV infection amongst 9-24-monthold children born to HIV positive
mothers

To assess the risk of acquiring and diagnosing HIV infection and/or dying by 24 months in children
born to HIV positive mothers in relation to their participation in the PMTCT program

To ascertain the level of stunting, wasting and underweight among children born to HIV infected
mothers

To evaluate the utilization of reproductive health services among women who tested HIV+ compared
to women who tested HIV –

To document the perception of users of PMTCT program services and the general community
14
II. METHODS
The study used both the quantitative and qualitative methodological approaches. This chapter describes
successively both approaches.
II.1 Quantitative methodological approaches
II.1.1. Study design
A cross-sectional household survey was conducted from February to May 2009 with HIV positive mothers and
their 9-24-month-old children. The study also included children 9-24-month-old born to HIV negative mothers.
The purpose of including children born to HIV negative mothers was twofold. On one hand, it served to ensure
that the community was blinded about study participants and to therefore avoid the stigma that would result in
including children exposed to HIV only. On the other hand, the data was used to compare the rate of utilization
of reproductive health services among HIV+ and HIV – women.
II.1.2. Sampling procedures
A stratified two-stage cluster sampling was used to select at first level health facilities and at a second level HIV
infected and HIV negative women from ANC records. At first level, health centers that had offered PMTCT
services for at least 36 months prior to the survey were stratified into urban and rural areas according to their
physical location. Then, a random sample of health centers was selected from each stratum with a probability
proportional to the size of the stratum. At the second level, a list of mothers who were expecting a child between
March 2007 and June 2008 was obtained using PMTCT and ANC records of health centers selected at the first
level. They were further divided into three groups based on PMTCT and ANC records: Mothers who tested HIV
positive during their ANC visit and who completed 4 ANC or more; Mothers who tested HIV positive during
their ANC visit but who did not complete 4 ANC; Mothers who tested HIV negative during their ANC visit. A
fixed number of mother-child pair was randomly selected from each group and then tracked back to their homes
for interviews.
II.1.3. Sample size estimation
In the absence of intervention, mother-to-child HIV transmission rate in developing countries is estimated to be
between 25% and 45% with a mid value of 35%. For the purpose of the study, we assume that since ARVs are
available at health facility level, the rate of MTCT of HIV will decrease from 35% to 25%. If PMTCT is
considered effective when it contributes to a reduction of HIV transmission rate of at least 10%, the expected
15
rate should not exceed 25% in the group that adhered to the program. We fixed the confidence level
95% and the statistical power
at
of 80% with the objective was to test the following hypotheses
H o : P1  P2 against H1 : P1  P2 ,
where
and
are the prevalence of HIV infection in children whose mothers did not participate in PMTCT
program and those for whom their mothers participated in PMTCT program respectively.
The required sample size (n) for a unilateral test with a confidence level of (1   ) and a test power of
(1   ) is given by the formula
n  {Z1
2
2P (1  P )  Z1  P1 (1  P1 )  P2 (1  P2 )}2 /( P1  P2 ) 2
where
P
P1  P2
2
Thus, the sample size required in each of the three groups of mother-child pair was estimated at 259 pairs. The
minimum sample size for each rural and urban area group was 777 (=259x3) statistical pairs. Since some
subjects could refuse to participate in the study, a non response rate of 10% was considered and applied by the
research team for the calculation of the total sample size. It led to a total sample size of 855 mother-child pairs
per each group (rural and urban areas). At country level, for both urban and rural areas, the total sample size was
1710 mother-child pairs. Taking into account the design effect resulting from the multistage sampling design,
the required sample size was increased up to 3420 mother-child pairs.
II.1.4. Questionnaires
At household level, two survey instruments were used to gather the information from the mother-child pairs:
mother’s questionnaire and child health assessment card. The mother’s questionnaire administrated to both HIV
positive and HIV negative mothers at their consent. This questionnaire was used to capture the information
about the knowledge of mothers about HIV in general and PMTCT in particular, the use of PMTCT services by
HIV positive women, the use of reproductive health services by all women and the role of male partners in use
of those services. Several variables including number of ANC visits, ARVs taken by mother and child, place of
delivery and feeding options were measured using this questionnaire.
The child health assessment card was used to record child basic demographics such as age and sex, their overall
health as well as their anthropometric and HIV status measurements.
The research team employed a number of research methods to develop and validate the questionnaires. A
literature review informed the development and selection of outcomes and predictors measured in this survey.
To ensure its cultural and conceptual appropriateness, the survey instrument was further refined in close
collaboration with PMTCT professionals. To assess the validity of the questionnaire and its application in the
16
Rwandan context, the instrument was finalized through pretesting. It was administered in Kinyarwanda, the
predominant language in Rwanda. Interviews lasted for about forty five minutes.
II.1.5. HIV testing and Anthropometric measurement amongst children
II.1.5.1. HIV diagnostic test
HIV infection in children was assessed from dried blood spots (DBS) collected on Guthrie cards by means of a
heel/finger prick during home visits at the time of the survey. HIV test was performed on three parallel rapid
tests: Determine, Unigold and Capillus. The algorithm followed for child HIV testing is displayed in figure 1
below. In two instances, results obtained from rapid tests had to be confirmed using a DNA PCR test. First, for
indeterminate or discordance of results between the 3 rapid test results were confirmed by PCR on DBS
collected. Second, if a child less than 18 months of age tested HIV+ on the rapid tests, results were also
confirmed using PCR on DBS collected. In all other cases, results of the three rapid tests were considered as
final.
A number of methods were used to control the quality of HIV testing. Every HIV rapid test batch was checked
for optimal performance using negative and positive controls by the laboratory technician in the field before the
testing of the samples collected. In addition, one sample out of every 20 samples tested with HIV rapid tests was
collected on DBS card and retested with PCR for Quality Control.
Figure 1: Child Blood testing for HIV program
II.1.5.2. Anthropometric measurement
During home visits, height and weight of children were measured and recorded on child health assessment card.
Height was measured using stadiometers and weight using digital scales.
17
II.2 Qualitative methodological approaches
II.2.1 Sample and study participants
Participants were recruited from all five provinces of Rwanda. In each province, one health facility among those
included in the quantitative study sample was selected randomly. Two health facilities were located in urban
area while three others were in rural settings.
In each health facility two focus groups were organized: one with HIV positive women and another
one with HIV negative women who used ANC/PMTCT services in the last 12 months. For each FGD,
eight to ten women HIV+ and the same were identified by the nurses in charge of PMTCT/ANC
services and invited to participate at least one week before the discussion. In total 75 women
participated in 10 FGD as indicated in table 1 below.
Table 1: Participants in focus group discussion
Provinces
District
Health Center (HC)
Location
Est
Ngoma
Zaza H.C.
Rural
North
Musanze
Ruhengeri H.C.
Urban
South
Kamonyi
Gihara H.C.
Rural
West
Karongi
Congo Nil H.C.
Rural
Kigali City
Kicukiro
Busanza H.C.
Urban
Total
5
5
Groups
Participants
HIV+
HIV HIV+
HIV HIV+
HIV HIV+
HIV Mixte
Mixte
10
6
4
7
6
9
10
9
11
7
6
75
II.2.2 Training of facilitators and piloting of guides
A team of two senior researchers from SPH were identified to coordinate the qualitative study implementation
and conduct the group discussions. Four interviewers were recruited to take notes, transcribe and translate the
data from Kinyarwanda into English. They were trained on qualitative data collection techniques in general and
focus group discussion in particular. Data collection instruments were developed in English and translated into
Kinyarwanda. They were then back-translated into English for cross-checking by the team. Corrections to the
Kinyarwanda versions were made as appropriate.
A pilot study was organized and one FGD was conducted with women attending ANC clinic of Bethsaida
Health Center in Kicukiro district to assess the guide flow and provide practice for the research team. The
18
interviewr guide was revised based on results of the pilot study. After Piloting and revision of the instruments,
two teams were composed each of one SPH researcher as moderator and two interviewers as note-takers.
II.2.3 Data collection techniques
The Focus Group Discussion method was used as data collection techniques to gather the information from
women who used ANC/PMTCT services in the last 12 months in all provinces of Rwanda.
II.2.4 Data collection procedures
All FGD were held at health centers or sector offices and were conducted in Kinyarwanda. The moderator
introduced the team and respondents were requested to introduce themselves. Then the team introduced the
purpose of the discussion, requested consent from participants, and invited participants to express their views
freely. As discussions were going on, soft beverages and snacks were offered to participants. Transport fees
were also provided.
II.3 Ethical procedures
Appropriate measures were taken to ensure survey participant protection, informed consent, voluntary
participation and confidentiality. In addition, formal review and approval of the instruments were obtained from
the Rwanda National Ethics Committee and the National Institute of Statistics. Interviewers and data entry staff
signed a confidentiality agreement with NURSPH, and also devoted one day of training on study pre-requisites
such as proper behavior, consent issues, etc.
In the field, interviewers read the required consent forms and obtained the approval of the interviewee prior to
proceeding with the actual interview or the collection of biological data. Investigators explained the aims of the
study, and the rights of research participants which include: the right to refuse to participate, to withdraw from
the study at any time, to refuse to answer any question, be informed of the potential risks and benefits associated
with the study, be provided with contact information for any questions, and have their confidentiality protected.
Names of the interviewees were de-linked from the results after data entry to protect the confidentiality of
personal information of household members. Following general Rwanda National Ethics Committee
recommendations, the School of Public Health will keep the completed questionnaires locked in a secure room
for duration of three years. Children from which biological data were taken were referred to the appropriate
Health facility for results, potential support, treatment, and follow up.
19
II.4 Data management and analysis
II.4.1 Quantitative data entry processing and analysis
Data entry was performed by a team of ten data entry personnel. Completed questionnaires were periodically
brought in from the field to the National University of Rwanda School of Public Health in Kigali, where two
data entry coordinators checked them before the actual data entry. Data were entered using CSPro 4.0. A quality
control program was used to detect data collection and/or data entry errors. This information was shared with
field teams during supervisory visits and weekly meetings to improve data quality. In addition, 10% of the
questionnaires were double entered for data quality control at entry. Data entered was later on exported to
STATA 10.1 for data analysis.
a.
Definition of the main outcomes
To respond to the study objectives presented earlier, several variables were defined as the outcome of interest.
Their operational definitions are presented in the table 2 below.
Table 2: Definition of outcome measures
Variable
Operational definition
Child death
Time to death
Child HIV infection
Child HIV infection and/or death
A binary variable indicating whether or not the child was deceased or
alive at the time of the survey
A continuous variable indicating the age of the child at death
A binary variable indicating whether or not the child was HIV infected
by 9-24 months
A composite indicator of whether the child was HIV infected by 9-24
months or dead by the age of 9 months.
Length-for-age Z-score
A continuous variable computed based on the WHO 2006 Child Growth
Standard
Weight-for-length Z-score
A continuous variable computed based on the WHO 2006 Child Growth
Standard
weight-for-age Z-score
A continuous variable computed based on the WHO 2006 Child Growth
Standard
Desire for future pregnancy
A binary variable indicating whether or not a woman desired to get
pregnant in the future
Use of contraceptive methods
A binary variable indicating whether or not the woman was using a
modern contraceptive methods
20
b.
Predictors
A number of variables were considered as potential predictors of the outcomes presented above. We can divide
these variables into three subcategories: individual, household variables, and measures for the prevention of
HIV transmission from mother to child. A definition of each of measures considered in the analysis is given in
tables 3 and 4 below.
Table 3: Individual and household variables used in the mother’s survey
Variable
Operational definition
Age of the mother
Household size
Marital status
Self-reported age of mothers at the time of survey (15-24, 25-29,30-34,
35-39, 40-44,45-49)
Number of people living in household at the time of survey
Marital status at time of survey (single/never married, living with a
partner, divorced/separated/widowed)
Decision-making power about health
and nutrition index
A composite index created to measure the extent to which the
respondent is involved in making household decisions related to health
and nutrition issues. Scores ranged from 0 – 100 and a higher score
indicates greater decision-making power.
Decision-making power about short
and long-term investment strategies
index
A composite index created to measure the extent to which the
respondent is involved in making household decisions related to short
and long-term investment issues. Scores ranged from 0 – 100 and a
higher score indicates greater decision-making power.
Religion
Educational attainment
Literacy
Membership to PLWH association
Housing material index
Household asset index
Water used in the household
Self-reported religious group
Highest level of attained education (none, primary, vocational training,
secondary, university)
A categorical variable indicating the level of literacy (can't or have
difficult reading and/or writing; can read but can't or have difficult
writing; can read and write easily)
A binary variable indicating whether the respondent is a member of
PLWH association or not
A composite index indicating whether roof, walls, and floors of the
respondent’s house is built in durable materials. The index ranged from
0 to 3; 0 meaning that none of the housing materials is durable while 3
meaning that materials for roof, walls and floors are durable.
A composite index indicating the number of valuable equipments
owned (Refrigerators, mobile telephone, radio, TV, car, …)
A binary variable indicating whether or not household has access to
piped water
21
Table 4: Adherence to PMTCT protocol: measures taken by HIV + mothers to prevent HIV transmission from
mother to child
Operational definition
ARV taken by the mother during
pregnancy
Place of delivery
ARV given to Infant
Infant feeding
Infant feeding at birth
c.
Type of ARV used by the mother during pregnancy (none; NVP alone, dual
therapy, tri-therapy)
Whether the respondent delivered at health facility or not
Whether or not the infant was given ARV prophylaxis (none, NVP alone,
dual therapy) at birth or within one month after birth
Whether or not the infant was appropriately fed by the time of survey.
Appropriate feeding options include: exclusive breastfeeding up to or before
6 months, exclusive replacement feeding after the first 6 months or exclusive
replacement feeding all the time.
A categorical variable of infant feeding practices adopted at birth
(Breastfeeding and early cessation, formula, and animal modified milk)
Analytical approaches
Several analytical approaches were used to respond to the study research objectives presented in previous
sections. Among them were descriptive statistics, Fisher exact test, Kaplan-Meier survival analysis, log rank
test, cox proportional hazard regression models, logistic regression and classical linear regression.
Descriptive and inferential statistics
For each variable under study, descriptive statistics, including central tendency and variance parameters, were
presented in order to describe the essential characteristics of the sample. Fisher exact and student’s t tests were
used to assess the difference in outcomes by potential predictors
The risk of dying
The risk of dying amongst children born to HIV infected mothers was compared to the risk of dying in children
of the same age but born to HIV negative mothers. The purpose of this comparison was to determine if children
born to HIV infected mothers might be at higher risk of dying than the rest of the children of the same age.
Kaplan-Meier survival analysis and the log rank test were used to evaluate the difference in survival between
children born to HIV positive mothers and those born to HIV negative mothers. Cox proportional hazard
regression models were used to study the relationship between maternal HIV serological status and child death.
Child HIV positivity
We also estimated the prevalence of HIV infection amongst 9-24-month old children born to HIV infected
mothers. We used Fisher exact tests to estimate the risk of HIV infection. We used logistic regression to
determine factors associated with HIV transmission.
22
HIV free survival at 9 months
We examine the risk of acquiring HIV infection and/or dying amongst 9-24-month old children born to HIVpositive mothers. In fact, combining the risk of acquiring and diagnosing pediatric HIV infection and the risk of
dying in the same period of time in a single estimator, might be a better study outcome than acquisition of HIV
infection alone, as the interventions evaluated in this report are intended to decrease the burden of pediatric HIV
infection and child mortality in the overall population. We used Fisher exact tests to determine risk for HIV
infection and risk of death, and derived HIV-free survival at 9 months. We used logistic regression to determine
risk factors of HIV transmission and/or death.
Nutrition status
Stunting, wasting, and underweight, were defined based on length-for-age, weight-for-length, and weight-forage Z-scores. The WHO classification was followed for assessing severity of malnutrition by percentage
prevalence ranges of these three indicators among children. Classical linear regression model was used to
evaluate the relationship between HIV infection and malnutrition among children.
Use of reproductive health services
Logistic regression models were also used to compare the use of reproductive health services among HIV + and
HIV – women.
We presented p-values and the conventional criteria (p<0.05) was used to identify statistically significant
differences. All data were weighted to account for the research design adopted.
II.4.2 Qualitative data processing and analysis
a. Transcription and translation
After data collection was complete, each interview was fully transcribed from two manuscripts from the notetakers and typed in word format. Transcripts were then translated from Kinyarwanda to English. For each FGD,
the primary document was formatted into Rich Text format and transferred into ATLAS.ti 5.8 Software to be
analyzed.
b. Codes definition, coding and analysis
One code book was initially created from the focus group guide and then enriched by details from a sample of
transcripts after data collection, to allow the categorization and analysis of the fieldwork data by topic or theme.
Researchers coded each 10 transcripts. Regular meetings were conducted to ensure database management and
facilitate the discussion on harmonization of codes as assigned to transcripts. Once codification was completed,
codes referring to the same topics or sub-themes were grouped into code families and outputs on specific
themes/codes were run and used for report writing. ATLAS- ti software was used to facilitate data analysis. The
23
first step in analysis was to identify analytic domains, major thematic areas, and minor thematic areas. Then the
data were interpreted and analyzed following the Grounded Data Theory
24
III. RESULTS
III.1. Description of survey participants
III.1.1 Survey participants
Of 3420 mother-infant pairs targeted for the mother and children survey, 3020 (88%) pairs living in catchment
areas of 105 health facilities were actually surveyed. This included 2982 mothers of whom 823(29%) were HIV
positives and had made less than 4 ANC visits, 611(20%) were HIV positive but had completed 4 or more ANC
visits and 1548(52%) were HIV negative. It is worth noticing that three out 108 health facilities selected for the
survey could not be either located or reached for the survey. In addition, about 12 percent of mother-child pairs
selected to participate in the survey could not be interviewed for several reasons. In some cases, mothers who
did not live in the catchment area of the health facility would give a false identity to benefit the incentives given
to HIV positive mothers who actually live in that catchment area. In other cases, contact information indicated
in PMTCT registries was not sufficient enough to locate the selected mother.
The sample included 3020 children of whom 2935(97%) were alive at the time of the survey but 85(3%) had
died before the survey (Figure 2).
Figure 2: Mother-child survey participants
25
III.1.2. Mother’s ARV uptake
As pointed out earlier, prior to interviews, HIV positive mothers were grouped into two groups: those who
completed 4 or more ANC visits and those who failed to do so, based on ANC/PMTCT registers. At the
household level, information on ARV and Opportunistic Infections (OI) prophylaxis taken by the mother and/or
the child were also recorded. Figure 3 below presents a summary of ARV and OI prophylaxis taken by the
mother during pregnancy.
On one hand, of 823 HIV positive mothers who completed less than 4 ANC visits, 243(29.53%) took neither
ARV nor Opportunistic Infection (OI) prophylaxis during pregnancy; 340(41,31%) took ARV prophylaxis, and
181(21.99%) took OI prophylaxis only. Of 340 mothers who took ARV prophylaxis during pregnancy,
90(26.47%) took NVP alone, 60(17.65%) were on dual therapy while 190(55.88%) were on triple therapy.
On the other hand, of 611 HIV positive mothers who completed 4 or more ANC visits, 134(21.93%) took
neither ARV nor Opportunistic Infection (OI) prophylaxis during pregnancy; 308(50,41%) took ARV
prophylaxis, and 127(20.79%) took OI prophylaxis only. In this group, of 308 mothers who took ARV
prophylaxis during pregnancy, 66(21.43%) took NVP alone, 48(15.58%) were on dual therapy while
194(62.99%) were on triple therapy.
26
Figure 3: ARV and/or OI uptake among surveyed HIV positive mothers
III.1.3. Characteristics of respondents and their households
Table 5 describes the socio-demographic characteristics of the respondent to mother’s survey. The majority
(more than 65%) of the respondents to the mother-children’s survey were less than 35 years old with HIVinfected women slightly older than HIV negative women (32 vs. 30 years on average). Most of the respondents
were living with a male partner (69% of HIV positive women vs. 87.68% of HIV negative women). It is worth
27
noting that about one in four of HIV + women were either separated or divorced or widowed while they
represent only 6% of HIV mothers.
Most of the respondents were either Catholic (42.53% of HIV positive women vs. 45.71% of HIV negative
women) or Protestant (40.64% of HIV positive women vs. 41.03% of HIV negative women). However, the
proportion of Muslim among HIV positive women was about two times higher than the proportion of Muslim in
HIV negative women (4.19% vs. 1.69%).
No significant differences in respondent’s educational attainment between HIV positive women and HIV
negative women. However, the literacy level seemed to be higher in HIV negative women than in HIV positive
ones (59.99% vs. 55.14%). A little more than half of HIV positive women (54.69%) were members of PLWH
association. It can be noted that a very small proportion (1.11%) of HIV negative women became members of
PLWH associations.
Table 5: Socio-demographic characteristics of the respondents by HIV status
HIV +
mothers
HIV –
mothers
P-value
Age, %, y (n=2969)
15-24
25-29
30-34
35-39
40-44
45-49
9.99
24.74
29.00
24.53
9.85
1.89
21.46
30.75
22.56
15.54
7.80
1.89
0.000
Mean age, y
32.18
30.09
0.000
Marital status, % (n=2963)
Single/never married
Lives with a partner
Separated/divorced/widowed
8.54
69.00
22.46
6.32
87.68
6.00
Religion, % (n=2970)
No religion
Adventist
Catholic
Protestant
Muslim
Others
1.61
9.85
42.53
40.64
4.19
1.19
0.91
9.88
45.71
41.03
1.69
0.78
Educational attainment, % (n=2965)
Never attended school
Primary school
Vocational/technical
Secondary school
University
24.72
67.58
2.59
4.83
0.28
23.03
69.49
1.76
5.66
0.07
Literacy, % (n=2969)
can't or have difficult reading and/or writing
can read but can't or have difficult writing
can read and write easily
40.04
4.82
55.14
36.15
3.97
59.88
0.000
0.001
0.155
0.029
28
Membership to a PLWH association,% (n=2954)
Yes
No
0.000
54.69
45.31
1.11
98.89
An analysis of respondent’s household characteristics reveals that there was no significant difference between
HIV positive mothers and HIV negative mothers (table 6). About one in five respondent’s households was
located in urban areas. An average of 5 people was living in each household.
The results on the housing index show that, on average, either roof or walls or floor of the house was built in
durable materials while the rest of the house was built in rudimentary materials.
The survey assessed also the ownership of durables goods by the respondents. The results show that the mean
ownership of durable goods was about one asset per household out of nine durable goods assessed by the
survey.
Table 6: Household characteristics of respondents by HIV status
HIV + mothers HIV – mothers P-value
Location , % (n=2982)
Rural
Urban
79.57
20.43
80.88
19.12
0.369
Household size, mean (SD) (n=2918)
Housing index, mean (SD) (n=2882)
Household asset index, mean (SD) (n=2948)
5.10(1.93)
1.38(0.82)
0.89(1.04)
5.10(1.96)
1.43(0.82)
1.16(1.11)
0.988
0.117
0.000
III.1.4 Level of participation in PMTCT program
Table 7 below is based on data from HIV positive women only and describes their level of participation in
PMTCT program by the number of ANC visits. Three components of PMTCT protocol including providing
appropriate ARVs to their child at birth, delivering at a health center and adopting appropriate feeding options
were assessed.
The results show that the prevalence of delivering in health facility was higher among women who had 4 or
more ANC visits than among women who had less than 4 ANC visits (93.33% vs. 86.63%, p=0.000).
It is worth to note that about 73.03% of the babies born to HIV positive mothers were given ARV prophylaxis at
birth or within 72 hours after birth.
However, only 8.60% of HIV positive mothers adopted appropriate feeding options and there was no significant
difference between those who had less than 4 ANC visits and those who had more. Furthermore, most HIV
positive mothers reported that they adopted either early breastfeeding (50.15%) or breastfeeding with early
cessation (33.14%) with no difference with regard to the number of ANC visits.
29
Table 7: Levels of participation in PMTCT program by ANC visits
Total
Less than 4 ANC
visits
4 or more ANC
visits
Child given ARV at birth, (n=1394)
None
NVP
Dual therapy
Don’t know
5.67
38.45
34.58
21.31
6.68
38.92
34.51
19.90
4.33
37.83
34.67
23.17
Mother delivered at health center, (n=1445)
Yes
No
89.48
10.52
86.63
13.27
93.33
6.67
P-value
0.0955
0.0000
Mother adopted appropriate feeding options,
(n=1360)
Yes
No
0.0858
8.60
91.40
7.59
92.41
9.95
90.05
Feeding options at birth, (n=1352)
EBF
BF and early cessation
Formula
Animal modified milk
50.15
33.14
10.06
6.66
57.96
57.37
58.09
47.78
42.04
42.63
41.91
52.22
0.328
III.2. Mortality among children 9-24-month old
This section uses the entire sample and assesses the rate of mortality among the cohort of children born between
March 2007 and June 2008. First, the section presents the crude mortality rates followed by some specific
mortality rates. Next, it assesses child survival among children by PMTCT program indicators. Lastly, it
explores the factors that are associated with mortality among the cohort under study with a special focus on the
difference in mortality rates among children born to HIV positive mothers and those born to HIV negative
mothers.
III.2.1. Mortality rate among children
Table 8 below presents the rate of mortality among children born between March 2007 and June 2008.
Crude mortality rate was about 28 per 1000 in this cohort of children.
The rate of mortality was significantly higher among children born to HIV positive mothers than among those
born to HIV negative mothers (4.19% vs. 1.53%; p=0.000). Furthermore, mortality rates were similar among
females and males (2.66% vs. 2.75% respectively; p=0.911) and among urban and rural residents (3.36% vs.
2.68% respectively; p=0.406).
30
Table 8: Mortality rates among children
Deceased
Alive
P-value
Sample, % (n=3020)
2.81
97.19
-
Child’s sex, %, (n=2995)
Female
Male
2.66
2.75
97.34
97.25
0.911
Mother HIV status, % (n=3020)
HIV positive
HIV negative
4.19
1.53
95.81
98.47
Residence, % (n=3020)
Urban
Rural
3.36
2.68
96.64
97.32
0.000
0.406
III.2.2. Child survival by 9-24 months
a. Child survival and mother’s serological status
We compared the survival curves among children born to HIV positive mothers and those born to HIV negative
mothers. The results of a Kaplan-Meier survival analysis (Figure 4) showed that children whose mothers are
HIV positive were more likely to survive shorter period than children whose mothers are HIV negative
(p=0.000).
A closer look at the Kaplan-Meier survival curve reveals that before the age of six months survival rates were
quiet similar in the two groups. However, after the age of 6 months, survival rates were higher when a child was
born to a HIV negative mother compared with children born to HIV positive mothers.
31
Figure 4: Child survival by mother’s serological status
0.90
0.92
0.94
0.96
0.98
1.00
Child survival by mother HIV status
0
2
4
6
8
10
12
14
Age
HIV -
16
18
20
22
24
HIV +
Chi2= 14.71, p=0.000, log rank test
b. Child survival and ANC visits
A Kaplan-Meier survival analysis (Figure 5) showed that children whose mothers visited ANC services for less
than four times survived a shorter period of time than children whose mothers had ANC for four times or more
(p=0.021).
32
Figure 5: Child survival by the number of ANC visits
0.90
0.92
0.94
0.96
0.98
1.00
Child survival by number of ANC visits
0
2
4
6
8
10
12
14
Child Age
less than 4 ANC
16
18
20
22
24
4 or more ANC visits
Chi2= 5.30, p=0.021, log rank test
c. Child survival and place of birth
The results of a Kaplan-Meier survival analysis (Figure 6) indicate that there was no significant difference in
rate of mortality between children born in health facilities and those born at home (p=0.810).
33
Figure 6: Child survival by place of birth
0.92
0.94
0.96
0.98
1.00
Child survival by place of birth
0
2
4
6
8
10
12 14
Age
Home
16
18
20
22
24
Health facility
Chi2= 0.06, p=0.810, log rank test
III.2.3. Factor associated with mortality in children 9-24-month old
a. Background characteristics and child mortality
A bivariate analysis revealed that maternal HIV serological status and their household assets were significantly
associated with child mortality (table 9). Child mortality was almost three times higher in children born to HIV
positive mothers than in those who were born to HIV negative mothers (4.19% vs. 1.53%, p=000).
Furthermore, ownership of assets were significantly lower on average in households that lost their children
compared to households whose children were still alive at the time of the survey (mean assets: 0.79 vs. 1.04,
p=0.033). The remaining background characteristics did not have a significant effect on child mortality.
34
Table 9: Child mortality by respondent and household characteristics
Child mortality
Deceased
Alive
HIV serological status, % (n=3020)
HV positive
HIV negative
4.19
1.53
95.81
98.47
Age, years, % (n=3007 ) 2
15-24
25-29
30-34
35-39
40-44
45-49
3.16
1.92
2.96
3.51
3.00
3.57
96.84
98.08
97.04
96.49
97.00
96.43
Marital status, % (n=3001)
Single/never married
Lives with a partner
Separated/divorced/widowed
4.04
2.59
3.31
95.96
97.41
96.69
Literacy, % (n=3006)
can't or have difficult reading and/or writing
can read but can't or have difficult writing
can read and write easily
3.15
3.82
2.54
96.85
96.18
97.46
90.65
83.43
89.48
82.95
P-value
Mother characteristics
Decision-making power
Health and nutrition issues, mean (SE) (n=3004)
Short and long term investment strategies, mean(SE) (n=3004)
0.000
0.456
0.310
0.451
0.590
0.872
Household characteristics
2
Location, % (n=3020)
Urban
Rural
3.36
2.68
96.64
97.32
0.406
Housing index , mean(SE) (n=2920)
Household assets index, mean(SE) (n=2984)
1.32
0.79
1.40
1.04
Access to clean water, % (n=2966)
Yes
No
2.69
3.11
97.31
96.89
0.357
0.033
0.556
Current mother’s age
35
b. Factors associated with child mortality
We modeled the hazard of death among children born between March 2007 and June 2008, by mother’s HIV
serological status and adjusting for other covariates. Categorical independent variables were coded as dummy
variables in the regression model. Stepwise selection with a probability of 0.05 for a variable to enter the model
and a probability of 0.15 to be removed from the model were used to test the model of the determinants of
hazard of death among children. Hazard ratios and their confidence intervals are displayed in the table 10 below.
The final model included three variables: mother’s serological status, the number of ANC visits and ownership
of assets index.
The risk of death in children born to HIV positive mothers was about 4 times as higher as in children born to
HIV negative mothers (aHR: 3.51, 95% CI: 1.73-7.10). The hazard of death was 50 percent lower among
children whose mothers visited four times or more ANC services than among children whose mothers visited
ANC services no more than one time (aHR: 0.50, 95% CI: 0.26-0.98). Furthermore, the final model indicated
that more assets owned by a household corresponded to lower risk of death in children (aHR: 0.78, 95% CI:
0.55-1.06).
Table 10: Cox proportional hazard regression models of time to death and factor associated with variability
in time to death among children
Hazard ratio
95% CI
Mother’s treatment during pregnancy (reference: HIV-)
HIV+:
3.51
1.73 – 7.10
Number of ANC visits (reference: less than four)
Four or more
0.50
0.26 – 0.98
Assets
0.78
0.55 – 1.06
36
III.3. HIV infection among children born to HIV positive mothers
The analysis in this section is based on data collected on children born to HIV infected mothers. First, we
estimate the prevalence of HIV in 9-24-month old children who were alive at the time of the survey. Next, we
perform bivariate followed by multivariable analysis of the relationship between HIV infection in those children
and PMTCT program indicators. Lastly, we present the results of analysis of HIV-free survival at 9-24 months
of age.
III.3.1. Laboratory testing results
The results of laboratory testing are displayed in the figure 7 below. A total of 2935 children were alive at the
time of the survey and targeted for HIV testing. Of those, 1723 (58.71%) were less than 18 months old and 1129
(38.47%) were 18 months of age or older. However, 83 (2.83%) children were not available for HIV testing at
the time of the survey. Among children who were less than 18 months old, 1662 (96.46%) tested HIV- while 27
(1.57%) tested HIV+ on rapid tests. HIV infection was confirmed with PCR test on 24 children. In children
below 18 months of age, refusal to be tested for HIV testing was noted in 32 cases (1.86%). Of the children who
were 18 months of age or older, 1084 (96.01%) tested HIV- while 26 (2.30%) tested HIV+ on rapid tests.
However, about 19 (1.68%) refused to be tested for HIV.
Table 11: Results of laboratory testing
37
III.3.2. HIV test quality control results
Thus, a subsample of 169 children (5.6% of the entire sample) was randomly selected for the quality control of
HIV testing results. Among those selected, the results of the rapid test indicated that 20 children (12%) were
HIV positive and 149(88%) were HIV negative. Nevertheless, the results of PCR test revealed that of the
children classified as HIV negative by the rapid tests 3.4 percent were HIV positive. In addition, all HIV
positive children by rapid tests were also HIV positive by the PCR (Fig.8.).
Figure 7: Results of quality control of HIV testing
III.3.3. Prevalence of HIV among children 9-24-month old
Table 11 below presents the prevalence of HIV infection in live children 9-24-month old.
The overall prevalence of HIV infection among children born to HIV+ women and who were alive at the time of
the survey was estimated at 3.96%. There was no significant difference in HIV infection either by gender, age of
the child, or whether they lived in rural or urban areas.
Table11: HIV prevalence among children 9-24 months born to HIV positive mothers
HIV serological status
HIV+
Pvalue
HIV-
Overall prevalence, % (n=1340)
3.96
96.04
Child’s sex, % (n=1324)
Female
Male
4.23
3.78
95.77
96.22
0.601
38
Child’s age, % (n=1340)
<=12
13 - 17
>=18
3.77
2.78
5.12
96.23
97.22
94.88
Residence, % (n=1340)
Urban
Rural
2.55
4.32
97.45
95.68
0.096
0.168
39
III.3.4. HIV infection among children 9-24-month old and PMTCT program
indicators
a. Bivariate analysis
a.1. Child HIV infection and PMTCT program indicators
The results of the relationship between child HIV serological status and PMTCT program indicators are
displayed in the table 12 below. Among PMCT program indicators assessed in this report, only the type of ARV
taken by the mother during pregnancy proved to be significantly associated with HIV serological status among
children (p=0.009). The prevalence of HIV infection seemed to be lower in children whose mothers were on
triple therapy (1.94%) and higher in children whose mothers did not take any ARVs during pregnancy (5.38%)
or those who took NVP alone (7.04%).
Table 12: Child HIV infection and PMTCT program indicators
HIV serological status
Child given ARV at birth, %(n=1340)
None
NVP
Dual therapy
Don’t know
Mother delivered at health center, %(n=1336)
Yes
No
Mother adopted appropriate feeding options, %(n=1307)
Yes
No
Feeding options at birth, %(n=1303)
EBF
BF and early cessation
Formula
Animal modified milk
Number of ANC visits, %(n=1340)
Less than four
Four or more
ARV taken by the mother, %(n=960)
None
NVP alone
Dual therapy
Triple therapy
HIV+
HIV-
6.49
4.45
3.64
2.87
93.51
95.55
96.36
97.13
3.75
5.19
96.25
94.81
1.77
4.10
98.23
95.90
4.40
3.99
2.29
1.15
95.60
96.01
97.71
98.85
4.32
3.47
95.68
96.53
5.38
7.04
4.81
1.94
94.62
92.96
95.19
98.06
P-value
0.283
0.332
0.131
0.166
0.387
0.009
.
40
a.2. Child HIV infection and demographic or socioeconomic characteristics of their mothers
We examined the differences in demographic and socioeconomic characteristics of the participants between
HIV positive and HIV negative children. The results of analysis indicate that only the age of the mother was
associated with the prevalence of HIV among children. Children born to young mothers (15 to 24 years old)
seem to be more infected (6.77%) and those born to mothers aged 35 to 40 are less infected (1.54%). There was
no significant effect of marital status, literacy, woman’s decision making power and or other household
characteristics (table13).
Table 13: Child HIV infection and demographic or socioeconomic characteristics of their mothers
HIV serological status
HIV+
HIV-
P-value
6.77
4.78
4.68
1.54
2.96
3.85
93.23
95.22
95.32
98.46
97.04
96.15
6.09
3.38
4.29
93.91
96.62
95.71
3.74
4.55
4.07
96.26
95.45
95.93
89.43(2.88)
90.20(0.55)
0.781
82.07(3.83)
84.35(0.73)
0.535
0.092
3.27
4.93
96.73
95.07
4.98(0.36)
1.55(0.12)
5.14(0.05)
1.37(0.02)
0.571
0.134
1.00(0.13)
0.90(0.03)
0.480
0.308
4.22
3.02
95.78
96.98
4.32
2.55
95.68
97.45
Mother’s characteristics
Age, % (n=1338)
15-24
25-29
30-34
35-39
40-44
45-49
Marital status, % (n=1336)
Single/never married
Lives with a partner
Separated/divorced/widowed
Literacy , % (n=1338)
can't or have difficult reading and/or writing
can read but can't or have difficult writing
can read and write easily
Decision-making power in health and nutrition issues index, mean (SE)
(n=1336)
Decision-making power in short and long-term investment strategies
index, mean (SE) (n=1336)
Membership to a PLWH association, % (n=1323)
Yes
No
Household characteristics
Household size, mean (SE) (n=1311)
Housing index , mean (SE) (n=1313)
Household assets index, mean (SE) (n=1329)
Access to clean water, % (n=1323)
Yes
No
Location, %(n=)
Rural
Urban
0.023
0.180
0.893
0.168
41
b. Multivariable analysis
Logistic regression model was used to assess the association between PMTCT indicators and child HIV
serological status controlling for other important factors. Since age of mothers was proved to be significantly
associated to HIV infection among children, it was added in model with PMTCT indicators. The results are
presented in the table 14 below. Children born to HIV+ women who received triple antiretroviral therapy were
63% less likely to be infected by HIV compared to children whose mothers did not take any ARV during
pregnancy(aOR: 0.37, 95% CI: 0.15-0.90). Prevalence of HIV among children born to mothers who received
either sd-NVP alone (aOR= 1.26; 95% CI: 0.63-2.50) or dual ARV therapy (aOR=1.08; 95% CI: 0.47-2.48) was
not significantly different from that of children born to mothers who did not receive any ARV prophylaxis.
Table 14: Results of logistic model of infant HIV infection
HIV serological status
Child given ARV at birth, (reference: none)
NVP
Dual therapy
Don’t know
Mother delivered at health center, ( reference: no)
Yes
Feeding options at birth, (reference: EBF)
BF and early cessation
Formula
Animal modified milk
Number of ANC visits, (reference: less than four)
Four or more
ARV taken by the mother, (reference: none)
NVP alone
Dual therapy
Triple therapy
Age, (reference: 15-24)
25-29
30-34
35-39
40-44
45-49
Odds ratio
95% CI
0.69
0.53
0.36
0.21 – 2.22
0.15 – 1.87
0.08 – 1.55
0.98
0.33 – 2.92
0.63
0.74
0.40
0.35 – 1.16
0.31 – 1.77
0.07 – 2.36
1.12
0.64 – 1.95
1.26
1.08
0.37
0.63 – 2.50
0.47 – 2.48
0.15 – 0.90
0.63
0.59
0.26
0.59
0.72
0.25 – 1.64
0.25 – 1.36
0.09 – 0.78
0.20 – 1.74
0.11 – 4.85
42
III.3.5. Child HIV infection and/or death by 9 months of age and PMTCT
indicators
In this section we examine the risk of acquiring HIV infection and/or dying amongst children born to HIVpositive mothers. HIV testing was done among alive children 9-24 months old whereas infant death was counted
if they died before reaching their ninth anniversary.
III.3.5.1. The risk of HIV infection and/or death by the age of 9 months
Of 1455 children born to HIV infected mothers, about 2.75% died by the age of 9 months while among 1340
children who were alive, 3.96% were HIV infected. This translates into HIV-free survival rates of 93.26 %(
95%CI: 92.05%-94.47%) (Table15).
Table 14: HIV infection and/or death among children
Death
HIV infection
HIV infection and/or
death
Unweighted
Total
No
Yes
%(95%CI)
%(95%CI)
1455
1340
1380
97.25 (96.34-98.16)
96.04(95.28-.96.81)
93.26(92.05-.94.47)
2.75(1.84-3.65)
3.96(3.19-4.72)
6.74(5.53-7.95)
43
III.3.5.2. Factors associated with Child HIV positivity and/or death by 9-24 months
We modeled the risk of HIV infection or dying by the age of 9-24 months among children born to HIV infected
mothers by the means of logistic regression models. Categorical independent variables were coded as dummy
variables in the regression model. Stepwise selection with a probability of 0.05 for a variable to enter the model
and a probability of 0.15 to be removed from the model were used to test the model of the determinants of either
acquiring HIV infection and/or dying among children born to HIV positive mothers. Odd ratios and their
confidence intervals are displayed in the table 16 below.
Three variables were included in the final model: mother’s HIV treatment, place of residence, and whether or
not the mother was a member of PLWH association.
Children whose mothers received highly active antiretroviral therapy (HAART) were about 51% less likely to
be infected by HIV and/or die compared to children whose mothers did not receive any ARV during pregnancy
(adjusted Odd Ratio (aOR): 0.49, 95%CI:0.28-0.86).
Being a member of a people living with HIV (PLWH) association (aOR=0.61, 95%CI:0.39-094) was also
associated with reduced likelihood of HIV infection among children.
Table 15: Results of logistic model of infant HIV infection and/or death
Child HIV positive
and/or death
Adjusted
odds ratio
ARV taken by the mother, (reference: none)
NVP alone
Dual therapy
Triple therapy
Location, (reference: rural)
Urban
Membership to a PLWH association, (reference: no)
Yes
95% CI
1.61
0.59
0.49
0.98 – 2.65
0.27 – 1.29
0.28 – 0.86
0.47
0.18 – 1.25
0.61
0.39 – 0.94
44
III.4. Nutrition status among children 9-24-month old
III.4.1. Level of nutrition among children
i) Level of nutrition among children
Anthropometric indices of infants are presented in Figure 7, 8, 9. Infants’ height-for-age (ZHA), weight-forheight (ZWH), and weight –or-age Z-scores (ZWA) were normally distributed. The mean ( standard deviation)
of ZHA, ZWH, and ZWA were -1.88 (1.5), 0.37 (1.5), and -0.66 (1.3), respectively. The coefficients of
skewness were 0.3, -0.23, and -0.23 for HAZ, WHZ, and WAZ, respectively. HAZ distribution was skewed to
the right, but WHZ and WAZ were virtually evenly distributed around zero. The kurtosis coefficient was nearly
3 for all anthropometric indicators WAZ (3.2), HAZ (2.9) and WHZ (3.1). These values are found in a normal
distribution. The prevalence of stunting, wasting, and underweight are elaborated on in subsequent sections.
0
.1
Density
.2
.3
Figure 8: Distribution of anthropometric indices (ZHA) among surveyed children
-6
-4
-2
0
2
4
ZHA
Mean ( SD): -1.9 (1.5) / Skewness: 0.5 and Kurtosis: 2.9
45
.15
0
.05
.1
Density
.2
.25
Figure 9: Distribution of anthropometric indices (ZWH) among surveyed children
-5
0
ZWH
5
Mean ( SD): 0.4 (1.5)/ Skewness: -0.23 and Kurtosis: 3.1
.2
0
.1
Density
.3
.4
Figure 10: Distribution of anthropometric indices (ZWA) among surveyed children
-5
0
ZWA
5
Mean ( SD): -0.66 (1.3)/ Skewness: -0.23 and Kurtosis: 3.2
46
ii) Nutritional status and infant's age
Figure 10 shows the results of nutrition status among HIV-exposed infants. Based on recommended cut-off
points, 2.28% of the reference population should lie below a cut-off of a -2 Z-score, 0.13% below a -3 Z-score,
and 15.8% below a -1 Z-score. Results from this study indicated that 48% of infants lay below a -2 Z-score for
chronic malnutrition. The prevalence of chronic malnutrition (stunting) was 35% and 53%, for infants <12
months, 12-24 months of age, respectively. Severe malnutrition, defined as a Z-score below -3 standard
deviation from the median of the reference population, was estimated at 26% for stunting in overall surveyed
sample. Infants above 12 months had the highest rate of severe chronic malnutrition (79%; P<0,000).
The prevalence of wasting and underweight, defined as a -2 SD of WLZ or WAZ from the median of the
reference population, was 8% for WLZ and 15% for WAZ. The prevalence of wasting was 10% for infants aged
below12 months and 6% for those above 12 months (P<0.00). However, the prevalence of underweight was
15.1% versus 15.4% for infants aged below and above 12 months, respectively; although the statistical
difference among these two groups were not significantly different from 0 (P=0.826). The severest forms of
wasting and underweight were 2% and 5%.
Figure 11: Nutritional Status by infant age
III.4.2. Nutrition status by level of participation in PMTCT program
i) Nutrition status by infant's HIV status
As discussed early, HIV infection among infants born to HIV+ mothers was estimated at 3%. The consequence
of being stunted is the result of inadequate nourishment over a long period of time or exposure to repeated or
chronic infections such as diarrhea for more than 2 weeks. Beyond 2 years, it is almost impossible to reverse a
child’s stunting status. In this case, it is more of a reflection of environmental, economic, or political instability.
Sometimes, stunting reflects a level of underdevelopment in a given country. This indicator is not sensitive to
47
short exposures such as seasonal changes. Although stunting rate was estimated at 48% in the overall sampled
infants, this prevalence doubled among HIV+ infants (73%) as shown in the figure below. Underweight (24% vs
15%) and wasting (8% vs 7.5%) were not as high as chronic malnutrition among HIV+ infants.
Figure 12: Nutrition status by infant's HIV status
ii) Association between adherence to PMTCT factors and nutritional status
The means and standard deviations of measures of nutrition status of sampled children and the factors related to
PMTCT are presented in Table 17.
Bivariate analyses show that delivery at health facility was associated with better weight-for-height (p=.001)
and weight-for-age Z-scores (p=.01). However, no association was found with height-for-age. Moreover,
infant's ARV intake, number of antenatal care (ANC) and mother's ARV intake were not associated with none
of the anthropometric indicators.
Table 16: Association between adherence to PMTCT factors and infant's nutritional status
HAZ
Variables
Place of delivery
Home / road
Health facility
ARV intake infant
None
NVP
Dual therapy
Number of ANC
<4
≥4
n
337 -1.81±.09
2301 -1.89±.03
WHZ
WAZ
Mean Zscore ± SE
.11±.09 **
.41±.03
-.83±.07*
-.64±.03
71 -1.75±1.8
475 -2.19±1.5
436 -2.10±1.4
.57±1.4
.53±1.6
.29±1.6
-1.45±1.2
-.70±1.3
-.82±1.3
1536 -1.90±.04
1105 -1.8±.04
.35±.04
.39±.05
-.69±.03
-.62±.04
ARV intake Mothers
48
None
Cotrimoxazole
NVP
Dual therapy
Triple therapy
341
253
132
97
332
-1.96±1.5
-2.0±1.6
-2.23±1.5
-1.79±1.4
-2.18±1.4
.31±1.5
.46±1.6
.60±1.7
.33±1.5
.47±1.6
-.74±1.3
-.67±1.3
-.67±1.5
-.62±1.3
-.74±1.3
** p<0.01, * p<0.05
iii) Association between infant feeding modes and infant's nutritional status
Infant feeding options at the onset of the interview was highly associated with nutritional status
(P<.001). Infants' mother who reported exclusively breastfeeding their infant during data collection period had
infants with better LAZ and WAZ compared to those who reported feeding their infant differently either
formula, breastfeeding and early cessation or modified animal milk. However, exclusively breastfed infants had
low WLZ compared to the rest of the group.
Table 17: Association between infant feeding modes and infant's nutritional status
LAZ
Variables
n
WLZ
WAZ
Mean Z score ± SD
Feeding options at birth
EBF
1902
-1.83±1.5
.32±1.6
-68±1.3
BF and early cessation
422
-2.0±1.4
.43±1.5
-.68±1.3
Formula
129
-2.02±1.4
.36±1.7
-.73±1.4
Animal modified milk
49
-1.82±1.6
.321±1.7
-.67±1.5
EBF
364
-1.56±1.5
.19±1.6
-64±1.3
BF and early cessation
124
-2.19±1.5
.31±1.4
-.86±1.3
Formula
62
-2.0±1.6
.29±1.7
-.77±1.4
Animal modified milk
395
-1.88±1.6
.44±1.7
-.61±1.3
No
2038
-1.91±1.5
.39±1.6
-.666±1.3
Yes
604
-1.78±1.5
.27±1.6
-.69±1.3
Actual feeding options
EBF up to 6 months
III.4.3. Factor associated with child nutritional status
Findings from a multivariate analysis on the effect of household and demographic characteristics as well as
clinical characteristics on HAZ, WHZ, and WAZ are presented in Table 19, testing the hypothesis that better
adherence to PMTCT will affect positively infant's nutritional status after controlling for other demographic and
household characteristics. There was no significant effect of all predictors with regard to WHZ, suggesting that
infant feeding pattern as well as demographic and clinical characteristics, considered as long term factors, do not
have any effect on recent nutrition status (WHZ).
However infant's HIV status as well as infant's age were strongly associated with HAZ. Older infants (> 1 year)
and non HIV infants had better LAZ compared to younger infants and HIV + infants. Based on the bivariate
49
analysis, results show that high proportion of older infants were well nourished in terms of appropriate feeding
practices compared to younger infants (80% versus 20%).
Moreover, women who reported having no employment or those with rudimentary roof or wall in their house
had infant with better nutritional status in relation to WAZ compared to those with enough wealth (estimated
using housing material as well as employment) as shown in table 19.
Table 18: Predictors of infant's nutritional status among infants born to HIV+ mothers
HAZ
Age of Infant (< 12 Mo)
Infant's sex (male)
Litteracy level (none)
Housing (modern materials)
Source of water
Employment (yes)
Infant' s HIV status (HIV-)
Feeding practices at birth
Actual feeding practices (EBF)
Place of delivery (road)
Number of ANC (< 4)
Child ARV (No)
Mother ARV (No)
0.91 (.20)***
-0.16 (.14)
-.11 (.08)
-0.98 (0.09)
-0.06 (.19)
.19 (.20)
1.07 (.41)**
-0.01 (.01)
0.01 (.002)
-0.07 (.28)
0.03 (.15)
.001 (.002)
-0.05 (0.04)
WHZ
-.63 (.35)
.26 (.27)
.06 (.15)
-.31 (.18)
-.15 (.34)
.13 (.41)
.24 (.61)
.0005 (.12)
.001 (.003)
.28 (.56)
-.28 (.29)
-0.07 (.004)*
-.07 (.07)
WAZ
.07 (.27)
.002 (.19)
.04 (.10)
-.29 (.13)**
-.12 (.24)
.95 (.35)***
.40 (.43)
-0.007 (.01)
-0.001 (.002)
.30 (.39)
-.01 (.20)
-0.002 (.003)
.002 (.05)
** p<0.01, * p<0.05
III.5. Use of reproductive health services by mother’s HIV status
III.5.1. Facility based versus home delivery
Taking ARV during pregnancy was highly associated to place of delivery, after controlling for other factors.
HIV positive mothers who took either a prophylactic treatment alone or with a three drug therapy were two
times as likely giving birth at a health facility as HIV negative women (table 20).
Table 19: Odds of delivering at a health facility and mother’s HIV treatment during pregnancy, adjusting for
other covariates
50
Odds
ratio
95% CI
Mother’s treatment during pregnancy (reference: HIV-)
HIV+: None/cotrimoxazole alone
HIV+: ARV prophylaxis/therapy
1.66
2.23
1.27 – 2.19
1.60 – 3.12
Number of ANC visits (reference: one)
2-3
4+
2.18
4.51
1.48 – 3.22
2.96 – 6.89
Number of live births ever had
0.84
0.80 – 0.89
Literacy (reference: can't or have difficult reading and/or writing)
can read but can't or have difficult writing
can read and write easily
1.52
1.60
0.87 – 2.68
1.26 – 2.02
Mother’s marital status (reference: Single/never married)
Lives with a partner
Separated/divorced/widowed
0.86
0.61
0.53 – 1.42
0.35 – 0.06
Assets index
1.21
1.07 – 1.37
III.5.2. Desire of future pregnancy
Table 21 below presents the results of logistic regression model of the desire to have more children by woman
HIV serological status. After adjusting for other factors, women who were HIV positive were about four times
as likely to express the desire to stop having children as women who were HIV negative (aOR=3.88; 95% CI:
3.03-4.97).
Table 20: Desire for future pregnancy and mother’s serological status
Unadjusted
OR(95%CI)
Mother characteristics
Adjusted
OR(95%CI)
HIV serological status (reference: HIV-)
HIV+
4.72(3.99-5.58)
3.88(3.03-4.97)
Number of live births ever had, per 1-birth increase
1.88(1.77 – 1.99)
1.85(1.70-2.01)
Literacy (reference: can't or have difficult reading and/or writing)
can read but can't or have difficult writing
can read and write easily
1.21(0.82-1.79)
0.97(0.82-1.14)
Marital status (reference: Single/never married)
Lives with a partner
Separated/divorced/widowed
0.92(0.68-1.23)
4.93(3.22-7.52)
0.30(0.21-0.44)
1.57(0.95-2.57)
Age, years(reference: 15-24)
25-29
30-34
35-39
40-49
2.82(2.18-3.64)
6.72(5.15-8.76)
13.54(9.98-18.35)
37.14(22.72-60.72)
1.86(1.37-2.53)
2.25(1.60-3.16)
2.54(1.69-3.82)
4.57(2.50-8.36)
51
Membership to a PLWH association, (reference: no)
Yes
4.32(3.50-5.34)
1.40(1.04-1.88)
Assets index, per 1-unit increase
0.86(0.80-0.92)
0.95(0.87-1.04)
III.6. Results from the qualitative survey
PMTCT clients in Rwanda are comprised first of all by both pregnant women then by a couple mother-children
living with HIV/AIDS, and secondary by their household members affected by the consequences of such
syndrome as their relatives or dependants. Thus, qualitative study explored as mentioned above the perception
of HIV/AIDS magnitude in community through PMTCT clients. Discussions were directed on the specifics
health problems that HIV+ women and their children are experiencing, the quality of services provided when
they attend PMTCT program and its effectiveness in term of preventing transmission of virus from mother to
child, and impact of health care received through the program on children from HIV+ parent’s health and
welfare. The qualitative study also analyzes the barriers to the optimum PMTCT services use whereas they are
available. These go from antenatal care for pregnant women to children follow up through post-partum and
health facility delivery. It further discusses the overall community attitude toward PMTCT clients’ behavior
about keeping give birth and whether or not they allow to disclose, and others community services provided
beside health services.
III.6.1 Problems facing PMTCT clients
PMTCT clients are mainly pregnant women, then HIV+ mothers and their children, and in recent couple of
years the woman’s partner for HIV testing. This section describes only the problems those HIV+ women and
their children are facing. Description doesn’t extend to the problems those HIV+ women’ partners are handling.
Both HIV positive and negative women clients of PMTCT program agreed that SIDA is an important health and
social problem in their respective community and that it causes particularly a great impeding to women living
with HIV+ and their children. They state that even though HIV/AIDS is not longer a serious illness since ART
are freely available to mitigate its sadness , it remains a burden disease among women whom still infected or
affected by the pandemic. In addition to the high prevalence of the disease within this category of population,
FGD participants recognize that HVI+ women face specific problems such as gender-based violence whose
perpetrators are often their partners, the discrimination done either by household members or by the rest of the
community. Both HIV positives and negatives women declare that sometimes, they suffer from the lack of their
partner’s cooperation when it comes the time to attend ANC and PMTCT because health facilities require the
couple to come together attending ANC for voluntary counseling and testing. Therefore this may constitutes an
obstacle for pregnant whom are not in harmony with their husband/partners as it will be explained furthermore
in the sections below. Another important problem that weights heavily on VIH+ women is poverty that
constraints them to run the mixture of breastfeeding because they can’t afford breastfeeding replacement. The
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followings sentences from rural participants illustrates the mothers practices surrounding baby from HIV+
mother feeding and how mother are embarrassed even though they know very well what should be done.
“..e.g. for us who are HIV+, when you give birth, they advise you to give breast to the baby up to the 6th month,
but because of poverty you are obliged to continue to breast feed the baby since you don’t have anything else to
feed him/her” …We are obliged to continue to breast feed our baby though we know we are infected because we
can’t allow the baby to starve”
The witnesses above show that there is a huge difference between knowledge and behavior especially when
PMTCT beneficiaries consider poverty as a contributing factor that amplify directly or indirectly the effects of
HIV on them and illustrates the rationale of treating HIV/AIDS in holistic dimensions to be really successful.
Findings from FGD point out also another important problem expressed by those HIV+ women attending or not
PMTCT program. Indeed, they face a long journey of hospitalization and as consequences psychological
feelings that result from their VIH+ status. For late problem pointed out, its occurrence is often among some
women it causes them to feel lonely and abandoned. The study points out also that the whole package of
VCT/PMTCT is not available near beneficiaries country wide and then women walk long distance to seek for
PMTCT and especially ART services an CD four account whereas they are weak. It is important to mention that
children borne from HIV negative clients of PMTCT do not benefits from a close follow up and this is a deal for
some participants. In fact, once their mother test negatives there is not a following test whereas they could get
infected any time of their lifetime. Such concern was raised by a group of participants from an urban area.
“We are not supporting the program of getting our children tested; we are worried of knowing that our children
can be positive. But if I am not HIV+ where can my child get the HIV?”
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III.6.2 PMTCT users’ perceptions of services provided
A. Services received
The way that customers perceive the quality of services is an important factor of the way they demand them.
The qualitative study on the effectiveness of PMTCT investigates the manner in what the clients perceive the
services they are being provided for. It passes through ANC provided to pregnant women, VCT for both
pregnant women and their partners, care given to HIV+ pregnant women still they deliver and post-partum
follow up to both mother and children for pinpoint the positives aspects of services PMTCT to strengthen and
negatives aspects to improve. The study collected also clients’ suggestions to be taken into account while
process improvement is being run.
The study invested first the package of services that women receive when they attend PMTCT program,
conditions under which they seek services, how they rate the quality of them and the factors related that
determine the demand of services.
Participants state that they get variety of services from PMTCT according to their status.
1 Pregnant women mentioned different types of care they receive while they attend antenatal care.
These cares range from pregnancy follow up to voluntary counseling and testing through screening of other
diseases symptoms, anti-anemia treatment, bed net supplies, and Niverapine to HIV+ mothers to prevent from
mother to child HIV transmission.
Beside VCT provided to all women attending antenatal care and their partners, those who test HIV+ positive
benefit post-test counseling on how they could keep healthy although they have virus and how they could give a
birth to a baby free from HIV infection. They are also advised on join or regroup into association in order to
work in synergy to overcome HIV consequences.
The conversations below between the researchers and group of FGD participants from a group of HIV+ women
in urban area witness how important are the services provided to women attending ANC. “It has been very
useful because we were just coming without knowing our status. Whenever they found that you are infected,
they were giving us advises so as to avoid propagation.
Before PMTCT, pregnant women were often killed by their pregnancy, or they died while giving birth to their
babies or the baby died or got infected. With PMTCT program, it has been useful to us since babies are now
born without being infected, and then life continues”
2 Pregnant women’ partners are HIV tested and counseled according to their test results.
3 HIV+ persons diagnosed through PMCT are given a close follow up for themselves especially CD4
count and treatment if relevant or their babies to be borne. They are also counseled on family planning and
provided with contraceptives, diet, and positive lifestyle.
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4 HIV+ pregnant women are treated to avoid transmission of HIV from them to their children and are
advised to give birth at health facility to allow them having babied free from HIV. The views of a HIV+ positive
woman from FGD participants in rural illustrate well the follow up done to avoid transmission from mother to
child.
“Even after birth they do a follow up when the child is born you are given a treatment used during bath and
given other anti-virus drugs to swallow”
In addition to health services, HIV+ mother who are clients of PMTCT benefit also social services
particularly to help having a suitable baby feeding. They are advised either to exclusively breastfeed their
newborns until six months old or to use breastfeeding replacement at the beginning. From one health facility to
another, HIV+ mothers are helped with breastfeeding replacement comprised by flour or a mixture of four and
milk or both but this assistance is not standardized none enough as it is stated by HIV+ positive women group in
these words.
“We are prohibited to breastfeed our babies. But because of lack of means, we are practicing a mixture. If they
could assist us to feed the babies by breastfeeding replacement like with milk and SOSOMA, it would be better”
B. Appreciation of PMTCT services
The study also examined whether or not clients appreciated the services they are receiving from PMTCT
program. Data from focus group discussions show that clients appreciate lot the services they receive while they
attend PMTCT program. Indeed, the program did great changes in beneficiary’s life conditions. It brings hope
for clients themselves, their offspring, and enhances their physical conditions. The following statement of an
HIV+ participant from remote areas shows how the program improves the physical conditions of persons living
with HIV/AIDS. “ Before knowing that I am HIV+, I used to get sick often but after knowing that I am HIV+
they gave me medicines and now, I am strong” According to FGD participants views, it appears that PMTCT
also contribute to rebuild harmony within a couple and to decrease disagreement in PMTCT clients
neighborhood as this views of a participants testimony. “… This is because there will be no conflicts when you
get back at home since you have been prepared to receive it and also you have been taught how to behave and to
cope with it.” A woman may get pregnant then get sick without knowing the diagnosis. In that circumstance, she
develops hate against her friends, but if tested and the truth is released, she gets easily reconciliation with her
neighborhood”
C. Perceived effectiveness of the PMTCT program
It is increasingly recognized that a combination PMTCT and VCT can play a critical role in the prevention of
HIV/AIDS transmission from mother to children in particular. However, this can only become effective when
demand for PMTCT is high among pregnant women and this late depends on how targeted group perceives the
effectiveness of the program. The present study discusses with women how they rate the Rwanda PMTCT
55
program effectiveness in terms of positive impact on their health, those of their children, and the rest of family
members.
C.1. Perceived impact of PMTCT program on mother
The findings indicate that the respondents acknowledge the benefits of PMTCT and those benefits include
diagnosis done while pregnant woman is attending antenatal care, the treatment that follows the diagnosis,
counseling and/or referral. In participants’ point of view, the benefits of PMTCT program on mother goes also
to couple harmony enhancement brought in by advise from health professional. PMTCT program contributes to
an increase of health facility delivery and then to lower the rate of mother death as this is witnessed by statement
of a group of HIV- participants from urban in these words. “There is HIV+ mothers who gave birth at home and
that caused deaths of children but now they come to the hospital and give birth to HIV- and healthy children”
C.2. Perceived impact of PMTCT program on children
The perceived effectiveness of PMTCT program on children health extends on the entire maternal and children
health which goes from antenatal care to postnatal care through tetanus vaccination to pregnant women ,
delivery care and place of delivery, assistance during delivery, vaccination of children , care of children hood
illness, and care and feeding practices for children borne from HIV+ mother. Findings from FGD show that
participants recognize the benefits for their children they get from the components of Rwanda PMTCT program.
They agreed that grace of PMTCT program, HIV+ mothers success to give birth to children frees from HIV
infection and that even though those who borne infected yet, PMTCT keep them healthy. They also recognize
that this advantage was not possible and not accessible to large number people before PMTCT program started.
For instance, a woman from semi-urban area explains her feelings for benefits of PMTCT program of children
in this sentence.
“Sometimes you were giving birth to a baby without being tested and the child was coming infected and may be
dead but now you know the status of your baby in the womb and again she/he can be born safely”
C.3. Perceived impact of PMTCT program on couple.
As it was mentioned in above section, the perceived effectiveness of PMTCT program in Rwanda goes beyond
the benefits on mother to encompass those of whole couple. The benefits of PMTCT program on couple include
but not only, the trust in, the harmony, and the economy when one of partners of both is healthy enough to be
productive for the family. Through PMTCT program couple gets tested and learns different manner of coping
with HIV/AIDS status. An HIV negative couple learns to protect each other against contamination and a
discordant couple is tough how to stay together without contaminating an HIV-partner. For HIV+ couple, it
learns how to keep healthy and the importance of family planning and how to manage if pregnancy happens in
HIV+ couple. The following sentence illustrates the perceived benefits of PMTCT program on couple as seen
by clients as it is expressed within focus group discussion with HIV+ women.
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“If you come at hospital with your husband, he goes back with something and together with the husband you
reach a common understanding of changing some behavior like spreading around VIH, having protected sex
relation since you all have got trainings”
C.4. Perceived impact of PMTCT program on family and community
Qualitative study especially its component of focus group discussions indicates that family members of PMTCT
and even the community benefits from the program. In their understanding, participants feel that the PMTCT
program mitigates the burden of HIV/AIDS on the family because it allows a couple to be tested and advised
according to test results. It is also an opportunity to get treated freely for those who test positive and this
discharge economically the family. PMTCT also advise family members of positive couple how to take care of
sick person without fear of being contaminated and without waste of money by going to the witch doctors.
For the whole community, the benefits of PMTCT are tremendous. As this come from both HIV positive and
negative participants in FGD, the program contributes in slowing the rate of disease spread in community and as
it was said previously the HIV diagnosis play a key role in stopping rumors and hatred in HIV/AIDS
neighborhood.
III.6.3 Critics of PMTCT services and suggestions for quality improvement
Although the majority of participants in focus group discussions appreciate lot the effectiveness of PMTCT
program, its impact on their owner health conditions, that of their children, partners and other households
members, they also have critics to consider and suggestions for quality improvement and better meet the client
needs.
The study carry out that participants wherever they come from agree that VCT done through PMTCT allows
HIV/AIDS diagnosis and then care that follow the diagnosis made a huge positive changes in their live. For
those who test negative, they behave accordingly and positively and for those who test positive, they are taken
care and become healthy, productive, and thanks to PMTCT, they could give birth to children free from HIV.
However, they criticize the fact that almost all health facilities require pregnant woman to be accompanied by
her partner even though when this is not possible. They cite an example of outside marriage pregnancy, woman
with husband abroad or who do not want to recognize the baby. For this issue, participants suggest an analysis
case per case and not make a general assumption as every single pregnant woman can easily be accompanied by
her partner for HIV counseling and testing. The statement below shows the feeling of a group of HVI+ women
from western Province. “You see when as girl you get pregnancy they tell you to come with the one who made
you pregnant”
Regarding the treatment itself, participants are unanimous to approve the effectiveness of ART no mitigating
the effects of HIV/AIDS and Niverapine on reducing transmission of HIV from mother to children but they
critic about the way that treatment is conduct. Those who are HIV+ and especially who are under treatment
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confess that ART increase appetite and when patient doesn’t have enough food to eat, he/she feel weak and
sometimes is constrained to stop medicines. For this issue they suggest that ART provisions be supplied with an
appropriate diet to accommodate HIV+ persons under treatment.
Among critics there is also a concern about the availability of services when some health centers do not offer the
whole package to HIV+ persons. It happens that some health centers have the capability but with a limited
capacity and women are tested but to get ART and to control for CD4, they walk long distance to reach health
facility which offers them. A suggestion is that every health facility be equipped to provide the whole package
for PMTCT. Beside the availability of services, there are also a matter of structures that do not allow
confidentiality and the behavior of some health workers who do not keep secret. The views of one HVI+
participant from remote health center illustrate the critics that go health workers behavior.
“On my own, I think it is a problem of not caring about patients because there are many workers in this health
center. I give the example of one day they closed the window of the pharmacy and went for lunch while they saw
that I was there and I needed medicines”
For this issue, it is an important thing to speed up the patient chart and let be known by both side: health facility
clients and health care providers.
Another critic is that there is not systematic follow up of HIV status of children whereas they can get infected
any time during their lifetime. Finally, findings from FGD carry out that services provided to PMTCT clients are
strictly limited on health care while those who test HIV+ needs more beyond health care to get an integrated
services that combines social services along with health care so that PMTCT can fully succeed.
III.6.4 Barriers to PMTCT use
A. Barriers to ANC attendance
i)
Ignorance
In all groups participants indicated ignorance as the most common reason preventing pregnant women to go for
ANC visits. They argued that there is no valid reason that can prevent pregnant women to go for ANC except
ignorance.
According to women using PMTCT services, ignorant women refuse to go for ANC visits because they do not
understand or see the benefits for them if they feel healthy. Others who had previous no complicated deliveries
for which they did not attend any ANC visit believe that all pregnancies will be the same and refuse to go for
ANC.
A few women argued that there are people who underestimate the importance of ANC because they do not
prevent from caesarean sections. Others mentioned the fact that there are few women who feel embarrassed and
ashamed to go for ANC because they had many children or because they were advised by providers to stop
having babies before.
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ii) Fear for HIV test and discrimination towards PLWHA
Since PMTCT program is integrated in ANC there are women who fear to be tested for HIV because they
cannot bear HIV+ status and others who know they are HIV+ and fear that their secret will be disclosed by
health providers to community volunteers who follow up on them.
According to some participants, women do not fear the HIV test but the discrimination and stigma they may
face in their family, and in their neighborhood.
A few women fear to be tested for HIV+ because they may be asked to not breastfeed their babies and prefer to
stay at home.
Some participants mentioned women who cheated on their husbands and fear the HIV test because they feel
guilty.
iii) Extra marital pregnancies
In all groups unmarried girls, widows and single mothers were mentioned to not attend ANC and PMTCT
program because they tend to hide their pregnancies to their families and neighbors. Moreover, the fact that they
are asked to come with their partners at the first ANC visit and because if they cannot be received without, they
prefer to stay at home until they deliver at home.
According to participants in all health centres, when a single mother comes for ANC/PMTCT she must bring a
letter from administrative authorities at the village level to testify that her husband/partner is not around (for
those working far away from their homes) or dead or unknown for unmarried ones. In most of the cases, those
women avoid this procedure because then the entire village will know that they are “illegally” pregnant and face
their disrespect if not their rejection.
iv) Partner
Partners and husbands were indicated by many participants as barriers to ANC/PMTCT services use by pregnant
women. Participants explained that a few partners/husbands refuse categorically to go with them at the health
facilities and therefore prevent those women to be received in ANC service. They explained that partners refuse
because of various reasons: some of them who know they are HIV+ but kept it from their wives; others refuse to
go because it is an unwanted pregnancy when they have been using some kind of Family Planning methods;
other men refuse to go for ANC/PMTCT because they fear to find out that they are HIV positive as they have
been having many partners. According to participant, there are men who prevent their wives to go for
ANC/PMTCT visits because they do not see themselves concerned as they are not the ones to be pregnant or
who refuses to sacrifice their jobs for ANC visits.
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v) Barriers from health facility
In some groups, women explained that health facilities can be the reasons why pregnant women may be
reluctant to use ANC/PMTCT services. The main barriers from health centres included poor quality of services
such as lack of personnel which results in a too long waiting time, limited capacity to do lab tests (all test results
are negative while they get positive to other health facilities), and lack of effective drugs; painful ANC
procedures (to measure the position of the foetus) and bad attitudes of some health care providers who are
disrespectful, irresponsible, neglectful and so forth.
Those participants explained that poor quality of services and bad attitudes of providers discourage pregnant
women to use their services because they delay services delivery and make communities loose trust into their
health facilities. Some participants explained that they may go seek ANC to remote health centres that offer
better services even if they have to pay much more transportation fees and much higher medical bill since they
cannot use their health insurance there.
vi) Household responsibilities
A few participants indicated that pregnant women do not use ANC services because they have no one to care for
their children when they go to health facilities. Other affirmed that it is due to ignorance because they can leave
them with friends or neighbors if not with relatives or their husbands. Some participants argued that women
with many children are those who fail to use ANC services because they are overwhelmed by housework
especially when they are single mothers.
vii) Long distance from home to health facilities
Participants in discussion had shared point of view about long distance being a barrier to ANC services use.
Some participants argued that long distance can prevent pregnant women to use ANC services. Others indicated
that if they come from far away they can manage to attend at least once the ANC if they really understand the
benefits of ANC and PMTCT services for them and their babies.
HIV+ women in particular stressed out that distance cannot be a barrier if pregnant women understand that these
services can save their children’s lives.
Vii) Others
Other barriers mentioned included poverty such as shame due to lack of clean clothes or shoes to wear; shyness
and advice from witches to avoid modern health services.
B Barriers to required number of ANC compliance
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Participants were asked about reasons why pregnant women do not respect the four standard ANC visits. Some
participants explained that the most common reason is that when women have no problems they just keep quiet
and wait until the last months to check their health status before they give birth.
Other reasons mentioned included household responsibilities, lack of support from husbands and relatives to
care for other children while they visit for no reason, limited transportation means and long distance.
“When you live far from the hospital because of weakness, poverty and many tasks, you prefer going to the
hospital only one time then give birth.” Said a woman from Musanze in the Northern Province.
C Barriers to health facility delivery
According to participants in discussion, the main cause of delivering at home or in the street was that in some
cases, women get surprised by the labour and deliver at home or before they reach the health facility. Other
reasons why they do not give birth in health facilities included lack of money for transportation or for medical
care, long distances, and lack of relatives to go with at health facility. Some participants indicated that some
women fear to be seen necked by many nurses
“There are some who fear to be seen naked by the nurses”, said a participant from Kigali city. HIV+ women
may avoid delivering at health facility because of stigma and fearing that her HIV status may be known by
others.
“There are times you advise someone going to the hospital but she refuses because of being afraid of what
people can think or say when they will know that she is HIV+.”As said a HIV + woman from Gihara in the
Southern Province.
“…getting afraid of people who will come to visit her to the hospital and see that she don’t breastfeed her
children.”As explained a participant from Kigali City.
II.6.5 Community attitude towards PMTCT program
A. Attitudes towards HIV test before giving birth.
In all provinces, ANC/PMTCT users who participated in the discussions explained that their communities had
started to understand that parents should be tested before they get married or start having children to protect
their children or decide not to have any if they are infected. In most places political and religious leaders require
couple to test for HIV before they get married.
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Some participants explained that being tested for HIV before having children also protect the couple to infect
each other, to worsen they health status if they get pregnant while they are HIV positive, and to avoid violence
and false accusations to each other later on.
Participants highlighted that only lovers who have sexual relationships before wedding risk to have unplanned
pregnancies and children without getting tested for HIV test.
B. Attitudes towards continuing giving birth while being HIV+
Participant’s opinion about having children while infected by HIV was shared. Some participant argued that
PLWHA should stop having babies because it weakens their bodies and jeopardize their lives and those of their
children.
Others explained that there are cases in which PLWH should have children such as young couples to have one
or two children but they should respect advices form health providers to protect them from getting infected.
C. Attitudes towards disclosure to children that their parents are HIV positive
All participants favored the idea that parents should tell their children about their HIV positive status. However
they had opposite opinion about when and what to tell children:
About the age at which children should be told their parents are HIV positive, some participants suggested to
inform children at the age of 5 to 7 when children start to go to school before they get the information from
other people or before their parents die. They explained that this can help them protect themselves and know the
risk to be HIV infected.
Others argued that children should be told that their parents are HIV+ at the age of 12 to 15, and explain them
why they must take medicines everyday to live longer and have them participate in taking care of their parents
(remind them to take drugs, to check for their health) and keep it a secret. They indicate that young children (5-7
years old) should not be told about their parents being HIV + to avoid them to be traumatized. Instead, they
should be told only about the disease and make sure they avoid sexual intercourse with other pupils and invite
them to discuss anything about their parents.
A few participants argued that children must be told the truth when they start suspect something wrong with
their parents regardless their age depending on each child either or not s/he can keep it a secret, take care of
other children in case the parent(s) die(s).
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“Today’s children become intelligent at an earlier age...... It is better to tell her/him without considering her/his
age, at the time she/he starts to question you.” As mentioned by a HIV+ woman from Northern Province.
D. Attitudes towards disclosure to children that they are HIV positive
Most of participants confirmed that children should be told they are HIV infected.
“Yes, they should be informed about their HIV-AIDS status because we have to
teach them on to take care of their selves so as not to spray it to others.” Said a woman from Congo Nil in the
Western Province.
About the age at which children should be told they are HIV positive, most of participants explained that
children should be told they are HIV + at the age of seven when they start ask questions and to be able to
convince them to take ARV every day.
“At the age of seven, you can tell him/her because at that age she/he begins to ask you why she/he takes
medicines”.As said a women form Zaza in the Eastern province
Some explained that telling a child of fifteen and above may lead him/her to be violent and misbehave because
of anger. Others argued that telling a child of less than 10 years old can be dangerous as the child may be
traumatized or say it loud with the risk of being rejected or marginalized by neighbours and other children; they
argued that children must be told at the age of ten to twelve or thirteen when they are able to understand and
keep a secret to avoid them telling anyone about it.
“When they are twelve years old because he/she is enough mature. “
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IV. CONCLUSION AND RECOMMENDATIONS
IV.1 Conclusion
The findings of the present study suggest that crude mortality in exposed Rwandan children was considerably
lower than the one observed in other African countries. Moreover, we showed that (12), irrespective of their
own infection status, mortality rates by six months of age for children born to HIV infected mothers are close to
general mortality rates but become higher by the age of 9 months. Our findings accord with previous findings of
high mortality in children exposed to HIV(13). Higher frequency of visits to ANC service and more household’s
assets were associated with lower risk of death in children.
HIV prevalence among 9-24 months living children and born to HIV+ mothers in the national PMTCT program
in Rwanda is low. This result is similar to the one observed in a study conducted in Malawi and Mozambique
(DREAM study). The study entitled “Extended prenatal ART protects against mother-to-child transmission of
HIV at low and high CD4 levels” reveals a reduction to 2% of HIV transmission by ART during pregnancy and
breastfeeding until 6 months age of the child. Maternal ARV treatment is negatively associated to HIV infection
among children. Mother ARV treatment or prophylaxis is associated with lower rates of HIV transmission from
mother to child.
HIV free-survival among HIV exposed children is high by 9-24 months in Rwanda, and could be further
improved by increased access to HAART for women eligible during pregnancy and ensuring that women
receive support from PLWH association.
For appropriate feeding, mothers are many to affirm that they are well informed about the dangers of mixfeeding. They confess that they do not respect it because of poverty. Since many of them cannot afford the
artificial feeding, neither they are unable to breastfeed only because they do not have enough milk due to poor
nutrition. To avoid child starvation, they are obliged to mix-feed their babies.
The current study showed that malnutrition rate among HIV+ children is high compared to non-HIV infected
children. In multivariate analysis, infant's HIV status as well as infant's age were strongly associated with HAZ.
Older infants (> 1 year) and non HIV infants had better LAZ compared to younger infants and HIV + infants.
Moreover, women who reported having no employment or those with rudimentary roof or wall in their house
had infant with better nutritional status in relation to WAZ compared to those with enough wealth (estimated
using housing material as well as employment) as shown in table 19.
Qualitative study pointed out a number of factors that undermine either PMTCT services attendance or its
effectiveness that need to be considered to improve program process then enhance the effectiveness. Those
factors are divided into individuals, community, institutional, and neutral ones. Individual factors include
extramarital pregnancy, fear to be seen necked by more than one health worker, fear of guilty, number of birth,
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and experience from previous labor. Community factors that impact PMTCT effectiveness are comprised
especially by discrimination and weak of social supports to PLWHA, such as discouragement from pregnant
women partners. Institutional factors regroup, less availability of entire package PMTCT services in some health
facilities, inadequacy of health structures, health workers misbehavior characterized by the lack of
confidentiality and secret,
partner antenatal care attendance requirement, and unacceptable waiting time.
Neutral factors include poverty that constrains HIV+ mother the practice to a mixture of breast and
complementary feeding for their children, geographic inaccessibility of PMTCT services. This qualitative study
documents also an idea that prescribing ART drugs only without diet accompanying it does not help many
beneficiaries
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IV. 2 Recommendations
1.
Efforts to promote the follow-up of children six months after delivery should be strengthened.
2.
HIV free-survival among HIV exposed children is high by 9-24 months in Rwanda, and could be
further improved by increased access to HAART for women eligible during pregnancy and ensuring
that women receive support from PLWH association.
3.
However, further improvements are needed to increase uptake of ARV prophylaxis for mother-baby
pairs and strengthen primary HIV prevention among HIV- women in ANC.
4.
Reinforce ART for pregnant women who are HIV+ as a way of reducing mother to child transmission
of HIV.
5.
To reduce overall child mortality in general and HIV related child mortality in particular, it is necessary
to reinforce mechanisms to ensure that mothers complete at least the recommended 4 ANC visits
6.
To improve access to PMTCT services there needs to be a continue the effort to increase the number of
Health facilities able to deliver ART
7.
Need to increase education and sensitization of men on the importance of the PMTCT program
8.
Need to identify and implement appropriate short term measures and sustainable long term measures to
curb the wasting and the stunting prevalence among children
9.
Health care providers have to support and guide mothers about the choice the infant feeding methods:
the AFASS conditions
10. Expand the ANC services and reinforce the sensitization on the 4 ANC visits because it has been
noticed that there is an inverse relationship between visits and MTCT.
11. Decrease the malnutrition rate by putting in place appropriate strategies not only for the HIV exposed
infants but to the entire population because this is a national problem.
12. Need to assess the incidence transmission rate of HIV from mother-to-child through a longitudinal
study
13. Assess the seroconversion rate among pregnant women (from their first up to delivery)
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V. REFERENCES
1. Annual Report 2007, Treatment and Research on AIDS Center, TRAC, Rwanda.
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