Prevention of mother to child transmission (PMTCT) of HIV in North-Eastern Botswana : clients and healthworker's perspective

Rationale Mother to child transmission of HIV is the predominant manner in which children acquire HIV. UNAIDS estimates 1800 HIV infected infants continue to be born every day in the developing world. In the absence of any interventions, the rate of transmission from mother to child is about 25-35 %. Nonetheless, in developed countries the impact of preventive interventions show a marked reduction in the number of children born infected with HIV. Botswana being one of the countries with the highest HIV prevalence among pregnant women initiated and implemented PMTCT strategies in 1999. These interventions are provided for free and are health facility based. Despite the availability of free services, only a few women use them and yet, the HIV prevalence continues to rise resulting in increased HIV infections and suffering of innocent children. For this reason, the researchers found it necessary to investigate possible contributory factors to low uptake of services with main focus on the recipients of care and the service providers. Objective The main objective of the study was to determine factors contributing to sub-optimal utilisation of PMTCT intervention strategies from clients and health workers viewpoints Setting The study was carried out in northeastern part of Botswana, which comprises the City of Francistown, Tutume sub-district, and the Northeast district. The two districts are peri urban. These areas are found near the Botswana-Zimbabwean boarder and are the entry and exit points to the popular tourist attractions and the diamond mine in northern Botswana. The Tutume sub-district and the City of Francistown have the highest HIV prevalence among pregnant women in Botswana; 55.5 and 49.6% respectively. Methods A cross-sectional study design with triangulation of quantitative and qualitative methods was used. Eight health facilities including a referral and a district hospital were conveniently chosen. A sample size of 397 women meeting the set criteria was selected for structured interviews. Another eight women and eight men participated in in-depth interviews. Eight health workers actively involved in provision of PMTCT service also participated in semistructured self-administered interviews while another eight were informants for in-depth interviews. Most interviews were conducted in health facilities except for men who were interviewed in their work places and in their homes. The local language (Setswana) andEnglish were used depending on the individual participant s preference and understanding. The researcher is fluent in both languages. An interview guide and a tape recorder were used for in-depth interviews. Data collected from PMTCT clients included; demographic, knowledge on MTCT, awareness of PMTCT interventions, view on men and PMTCT, extended family and PMTCT, and satisfaction/dissatisfaction with PMTCT services. Participants also provided information on what they perceived as motivators and barriers for using the interventions. Although information from health workers covered similar areas, some additional themes included; period of training for PMTCT counsellors, view on training, interest in counselling and in the program, and view on implementation and use of services. Additionally, information regarding PMTCT vs. regular workload and challenges experienced in providing services was obtained. All the data obtained were anonymized, coded and entered in codes in the computer using the Statistical Package for Social Sciences (SPSS) 11.0. This data was cleaned and double checked for any entry errors. Also, Chi-square at the significance level of 0.05 was used for analysis. Especially for in-depth interviews, analysis was carried out thought the data collection process. Further, transcription of tape-recorded information was done. NUDIST software was used to categorise data into main themes. Throughout this process, logical reasoning was applied based on the socio-cultural understanding of the community under study by the researchers in order to give meaning accordingly. Results Of the 397 women interviewed, only 14% of them were married. 73% of all the women had a lower educational attainment (up to 10 years). All women had some knowledge on MTCT/PMTCT and 55% of them discussed with their partners. Most of those who discussed were of higher educational level. Most women indicated to be satisfied with the services they received while health workers expressed their dissatisfaction with the quality of services they provide. Fear of male partners and fear of knowing status are some of the main barriers and this is consistent with the set hypothesis. Conclusion This study suggests that health workers are committed to providing services especially with the level of political/government support in relation to free services. However, manpower constraints and lack of supervisory support are shown to be the stumbling block. Higher educational attainment among women is significant for discussing PMTCT with partners. Community mobilisation, improvement in staffing and supervisory support is important for the success of the program