Understanding the barriers and facilitators to the retention of HIV positive women along the prevention of mother-to-child transmission of HIV (PMTCT) continuum in Kenya

BACKGROUND: Kenya has made a commitment to virtually eliminate mother to child transmission of HIV (MTCT) by 2015. To achieve virtual elimination, the prevention of MTCT (PMTCT) programs must achieve high coverage and retain HIV-positive women throughout the PMTCT continuum of care. METHODS: A mixed methods study was conducted in three health facilities in Kenya. To quantify retention along the PMTCT care continuum, a retrospective chart review was conducted on HIV positive pregnant or recently-delivered women 18 or older presenting for antenatal care or delivery between January 2012 and May 2013. The primary outcome was retention at individual and facility levels through 18 months postpartum. Logistic regression analysis was performed to determine predictors of retention. Semi-structured in-depth interviews were conducted with HIV positive women and male partners to understand barriers and facilitators of retention in PMTCT care. A failure mode and effect analysis was conducted to identify potential failures along the PMTCT cascade. RESULTS: Across the study sites, only 9%, 10% and 16% of the cohort was fully retained. The retention decreased significantly along the PMTCT cascade from antenatal to the postnatal phase. Gestational age at first antenatal visit (p= 0.043) and the number of antenatal visits attended (p=0.036) were identified as significant predictors of non-retention in PMTCT care. The facilitators of retention included acceptance of HIV positive status, supportive male partners, disclosure of HIV status to male partners and family, peer counseling and psychosocial support, and positive experiences with healthcare providers. Identified barriers were the inverse of the facilitators and were reinforced by stigma, financial pressure, and stress. The failure modes identified along the cascade included: missed opportunities for HIV testing and delivery of PMTCT interventions at antenatal, poor quality of data, loss of infant’s HIV test results, long wait times, and poor linkage between health facilities. CONCLUSION: Retention along the PMTCT continuum of care was low at the study facilities. The facilitators and barriers of retention comprised an interaction of personal, societal and structural dynamics operating simultaneously. The results provide the needed context and important considerations in the improvement of PMTCT implementation strategies as Kenya transitions to provide lifelong ART