Study reveals adherence gap in preventing mother-to-child transmission
Ugandan study finds uptake of HIV treatment above 90%, but only three-quarters of women were fully taking medication after two months
A study among pregnant women living with HIV in central Uganda has found only three-quarters were fully adhering to antiretroviral treatment (ART) after two months.
The study, published in PLOS One, found 91% of women diagnosed with HIV while pregnant were offered ART. But after two months, 24% – nearly one in four – were not taking their medication properly.
Uganda began offering lifelong ART to pregnant and breastfeeding women living with HIV in 2012 through its Option B+ scheme.
Researchers followed 507 pregnant women living with HIV who had been newly enrolled on ART through Option B+ at six health facilities in Masaka, Mityana and Luwero, some of the first Ugandan districts to offer the scheme. The women answered questionnaires at regular intervals between October 2013 and March 2016. Interviews were also carried out with 54 health service providers and 57 pregnant and breastfeeding women enrolled in Option B+ services.
Around one-quarter (27%) of women had received an ART prescription within four weeks of diagnosis, and by two months 91% had. The majority of women (93%) started taking their medication as soon as they received it. Most women (88%) who had not received an ART prescription two months after their HIV diagnosis reported being willing to start ART, indicating a missed opportunity.
The main things that motivated women to accept ART was a desire to be healthy (92%) and a desire to protect their baby (90%). Advice from health providers, a desire to live longer, fear of HIV symptoms being noticed, and encouragement from partners also motivated women to take medication.
Although uptake of treatment was high, only 76% of women were fully adhering to ART after two months of starting it. This is worrying, since evidence shows people are more likely to be motivated to take medication properly in the earlier stages of treatment.
The reasons women were struggling to properly take treatment included the need to travel long distances to health facilities for refills, side effects, not telling anyone they were living with HIV and so hiding their pills, forgetting to take medication, and a misconception that, after giving birth, their baby was no longer vulnerable to HIV.
Around 80% of women said they were ready to take ART as soon as they were prescribed it, and this group was the most likely to fully adhere to treatment.
Around one in ten women with an ART prescription (13%) said they wanted to delay starting treatment, while 5% reported not being ready at all. These women were less likely than those who were ready to be adhering after two months.
The most common reasons for delaying ART were a desire for more time (53%) before starting treatment, a lack of information about Option B+ (23%), and desire for a confirmatory HIV test (9%). The most common reasons for not ever wanting to take-up ART were fear of being on ART for life, being seen by a partner taking antiretroviral (ARV) medication, possible side effects, doubting their HIV diagnosis, and preferring to take herbs as treatment. A few women wrongly thought that people die faster if they take ARVs than if they don’t.
ART adherence was higher among women who had told their partner or a close friend or relative they were living with HIV, and among women who had received information and counselling about HIV and knew the benefits of ART.
The findings suggest women who are not ready to start treatment should be given time to accept their HIV diagnosis and provided with enough education, counselling and support to understand the benefits of lifelong ART, and to dispel misinformation. To aid this, the Ugandan Ministry of Health should introduce appropriate training, guidelines, supervision and mentorship for health workers to improve the quality of counselling and support on offer.
There is also a need to carefully track women once they are prescribed ART and provide extra support for those who have challenges with adherence in the first few months of treatment. Using peer supporters to do this could be an effective way to reach women.
Supporting women to tell their partner and/or a close friend or relative about their HV diagnosis could also help some women living with HIV get the emotional and practical support they need to keep taking their medication.