“I do all I can but I still fail them”: Health system barriers to providing Option B+ to pregnant and lactating women in Malawi


Autoři: Nozgechi Phiri aff001;  Kali Tal aff001;  Claire Somerville aff004;  Malango T. Msukwa aff001;  Olivia Keiser aff001
Působiště autorů: Institute of Global Health, University of Geneva, Geneva, Switzerland aff001;  Baobab Health Trust, Lilongwe, Malawi aff002;  Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland aff003;  Gender Centre, Graduate Institute, Geneva, Switzerland aff004
Vyšlo v časopise: PLoS ONE 14(9)
Kategorie: Research Article
doi: https://doi.org/10.1371/journal.pone.0222138

Souhrn

Malawi’s Option B+ program is based on a ‘test and treat’ strategy that places all HIV-positive pregnant and lactating women on lifelong antiretroviral therapy. The steep increase in patient load placed severe pressure on a health system that has struggled for decades with inadequate supply of health care workers (HCWs) and poor infrastructure. We set out to explore health system barriers to Option B+ by asking HCWs in Malawi about their experiences treating pregnant and lactating women. We observed and conducted semi-structured interviews (SSIs) with 34 HCWs including nine expert clients (ECs) at 14 health facilities across Malawi, then coded and analyzed the data. We found that HCWs implementing Option B+ are so overburdened in Malawi that it reduces their ability to provide quality care to patients, who receive less counseling than they should, wait longer than is reasonable, and have very little privacy. Interventions that increase the number of HCWs and upgrade infrastructure to protect the privacy of HIV-infected pregnant and lactating women and their husbands could increase retention, but facilities will need to be improved to support men who accompany their partners on clinic visits.

Klíčová slova:

People and places – Population groupings – Professions – Medical personnel – Geographical locations – Africa – Malawi – Medicine and health sciences – Health care – Health care providers – Nurses – Health education and awareness – Women's health – Maternal health – Antenatal care – Pregnancy – Obstetrics and gynecology – Pathology and laboratory medicine – Pathogens – Immunology – Public and occupational health – Preventive medicine – Antiviral therapy – Diagnostic medicine – HIV diagnosis and management – Biology and life sciences – Microbiology – Medical microbiology – Microbial pathogens – Viral pathogens – Immunodeficiency viruses – HIV – Retroviruses – Lentivirus – Organisms – Viruses – RNA viruses – Vaccination and immunization


Zdroje

1. World Health Organisation (WHO). Use of antiretroviral drugs for treating pregnant women and preventing HIV infection in children [Internet]. World Health Organization (WHO); 2012. Available: https://www.who.int/hiv/PMTCT_update.pdf

2. Kalua T, Tippett Barr BA, van Oosterhout JJ, Mbori-Ngacha D, Schouten EJ, Gupta S, et al. Lessons Learned From Option B+ in the Evolution Toward “Test and Start” From Malawi, Cameroon, and the United Republic of Tanzania: JAIDS J Acquir Immune Defic Syndr. 2017;75: S43–S50. doi: 10.1097/QAI.0000000000001326 28398996

3. Kiragu K, Collins L, Von Zinkernagel DB, Mushavi AMbc. Integrating PMTCT Into Maternal, Newborn, and Child Health and Related Services: Experiences From the Global Plan Priority Countries. J Acquir Immune Defic Syndr. 2017; doi: 10.1097/QAI.0000000000001323 28398995

4. Gunda A, Joseph J, Mwapasa V. Integrating HIV and Maternal, Neonatal and Child Health Services in Rural Malawi: An Evaluation of the Implementation Processes and Challenges. J Acquir Immune Defic Syndr. 2017;75: 8.

5. on behalf of the Lablite team, Cataldo F, Seeley J, Nkhata MJ, Mupambireyi Z, Tumwesige E, et al. She knows that she will not come back: tracing patients and new thresholds of collective surveillance in PMTCT Option B+. BMC Health Serv Res. 2018;18. doi: 10.1186/s12913-017-2815-x

6. WHO. Implementation of Option B+ for Mother to Child Transmission of HIV: the Malalwi experince [Internet]. World Health Organization (WHO); 2014. Available: http://apps.who.int/iris/bitstream/handle/10665/112849/9789290232520.pdf?sequence=1&isAllowed=y

7. Ministry of Health, Malawi. Malawi Population- based HIV Impact Assessment (MPHIA) 2015–2016: Final report [Internet]. Ministry of Health, Malawi; 2018 Oct. Available: https://phia.icap.columbia.edu/wp-content/uploads/2018/10/MPHIA-Final-Report__10.25.18.pdf

8. WHO. Policy brief: Consolidated guidelines on the use of ART for treating and preventing HIV infection: what’s new. WHO; 2015.

9. Small E, Nikolova SP. Attitudes of Violence and Risk for HIV: Impact on Women’s Health in Malawi. Sex Cult. 2015;19: 659–673. doi: 10.1007/s12119-015-9285-2

10. Colombini M, James C, Ndwiga C, team I, Mayhew SH. The risks of partner violence following HIV status disclosure, and health service responses: narratives of women attending reproductive health services in Kenya. J Int AIDS Soc. 2016;19. doi: 10.7448/IAS.19.1.20766 27037140

11. Dovel K, Yeatman S, Watkins S, Poulin M. Menʼs heightened risk of AIDS-related death: the legacy of gendered HIV testing and treatment strategies. AIDS. 2015;29: 1123–1125. doi: 10.1097/QAD.0000000000000655 26035315

12. Phiri N, Haas AD, Msukwa MT, Tenthani L, Keiser O, Tal K. “I found that I was well and strong”: Women’s motivations for remaining on ART under Option B+ in Malawi. PLOS ONE. 2018;13: e0197854. doi: 10.1371/journal.pone.0197854 29874247

13. Lumbantoruan C, Kermode M, Giyai A, Ang A, Kelaher M. Understanding women’s uptake and adherence in Option B+ for prevention of mother-to-child HIV transmission in Papua, Indonesia: A qualitative study.: 17.

14. Elwell K. Facilitators and barriers to treatment adherence within PMTCT programs in Malawi. AIDS Care. 2016;28: 971–975. doi: 10.1080/09540121.2016.1153586 26984065

15. Chadambuka A, Katirayi L, Muchedzi A, Tumbare E, Musarandega R, Mahomva AI, et al. Acceptability of lifelong treatment among HIV-positive pregnant and breastfeeding women (Option B+) in selected health facilities in Zimbabwe: a qualitative study. BMC Public Health. 2018;18. doi: 10.1186/s12889-017-4611-2 28743251

16. Kim MH, Zhou A, Mazenga A, Ahmed S, Markham C, Zomba G, et al. Why Did I Stop? Barriers and Facilitators to Uptake and Adherence to ART in Option B+ HIV Care in Lilongwe, Malawi. PloS One. 2016;11: e0149527. doi: 10.1371/journal.pone.0149527 26901563

17. Amy Zhou. The uncertainty of treatment: Women’s use of HIV treatment as prevention in Malawi.

18. Jahn A, Harries AD, Schouten EJ, Libamba E, Ford N, Maher D, et al. Scaling-up antiretroviral therapy in Malawi. Bull World Health Organ. 2016;94: 772–776. doi: 10.2471/BLT.15.166074 27843168

19. Government of the Republic of Malawi. Health Sector Strategic Plan II 2017–2022. p. 140.

20. Tenthani L, Haas AD, Tweya H, Jahn A, van Oosterhout JJ, Chimbwandira F, et al. Retention in care under universal antiretroviral therapy for HIV-infected pregnant and breastfeeding women (‘Option B+’) in Malawi: AIDS. 2014;28: 589–598. doi: 10.1097/QAD.0000000000000143 24468999

21. Tweya H, Oboho IK, Gugsa ST, Phiri S, Rambiki E, Banda R, et al. Loss to follow-up before and after initiation of antiretroviral therapy in HIV facilities in Lilongwe, Malawi. Beck EJ, editor. PLOS ONE. 2018;13: e0188488. doi: 10.1371/journal.pone.0188488 29373574

22. Flax VL, Yourkavitch J, Okello ES, Kadzandira J, Katahoire AR, Munthali AC. “If my husband leaves me, I will go home and suffer, so better cling to him and hide this thing”: The influence of gender on Option B+ prevention of mother-to-child transmission participation in Malawi and Uganda. Anglewicz P, editor. PLOS ONE. 2017;12: e0178298. doi: 10.1371/journal.pone.0178298 28594842

23. Helova A, Akama E, Bukusi EA, Musoke P, Nalwa WZ, Odeny TA, et al. Health facility challenges to the provision of Option B+ in western Kenya: a qualitative study. Health Policy Plan. 2016; czw122. doi: 10.1093/heapol/czw122 28207061

24. Haas AD, Tenthani L, Msukwa MT, Tal K, Jahn A, Gadabu OJ, et al. Retention in care during the first 3 years of antiretroviral therapy for women in Malawi’s Option B+ programme: an observational cohort study. Lancet HIV. 2016;3: e175. doi: 10.1016/S2352-3018(16)00008-4 27036993

25. Haas AD, van Oosterhout JJ, Tenthani L, Jahn A, Zwahlen M, Msukwa MT, et al. HIV transmission and retention in care among HIV-exposed children enrolled in Malawi’s prevention of mother-to-child transmission programme. J Int AIDS Soc. 2017;20: 21947. doi: 10.7448/IAS.20.1.21947 28884524

26. Ministry of Health Malawi. Malawi HIV Testing Services Guidelines. 2016; 62.

27. Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nurs Health Sci. 2013;15: 398–405. doi: 10.1111/nhs.12048 23480423

28. Braun V, Clarke V, Hayfield N, Terry G. Thematic Analysis. In: Liamputtong P, editor. Handbook of Research Methods in Health Social Sciences. Singapore: Springer Singapore; 2019. pp. 843–860. doi: 10.1007/978-981-10-5251-4_103

29. Muula AS. Shortage of health workers in the Malawian public health services system: how do parliamentarians perceive the problem? J Health Sci. 2006;13: 7.

30. Cataldo F, Chiwaula L, Nkhata M, van Lettow M, Kasende F, Rosenberg NE, et al. Exploring the Experiences of Women and Health Care Workers in the Context of PMTCT Option B Plus in Malawi: JAIDS J Acquir Immune Defic Syndr. 2017;74: 517–522. doi: 10.1097/QAI.0000000000001273 28045712

31. Bradley S, Kamwendo F, Chipeta E, Chimwaza W, de Pinho H, McAuliffe E. Too few staff, too many patients: a qualitative study of the impact on obstetric care providers and on quality of care in Malawi. BMC Pregnancy Childbirth. 2015;15. doi: 10.1186/s12884-015-0492-5 25880644

32. McLean E, Renju J, Wamoyi J, Bukenya D, Ddaaki W, Church K, et al. ‘I wanted to safeguard the baby’: a qualitative study to understand the experiences of Option B+ for pregnant women and the potential implications for ‘test-and-treat’ in four sub-Saharan African settings. Sex Transm Infect. 2017;93: e052972. doi: 10.1136/sextrans-2016-052972 28736391

33. Katirayi L, Namadingo H, Phiri M, Bobrow EA, Ahimbisibwe A, Berhan AY, et al. HIV-positive pregnant and postpartum women’s perspectives about Option B+ in Malawi: a qualitative study. J Int AIDS Soc. 2016;19. doi: 10.7448/IAS.19.1.20919 27312984

34. Gugsa S, Potter K, Tweya H, Phiri S, Sande O, Sikwese P, et al. Exploring factors associated with ART adherence and retention in care under Option B+ strategy in Malawi: A qualitative study. Okulicz JF, editor. PLOS ONE. 2017;12: e0179838. doi: 10.1371/journal.pone.0179838 28636669

35. Chan AK, Kanike E, Bedell R, Mayuni I, Manyera R, Mlotha W, et al. Same day HIV diagnosis and antiretroviral therapy initiation affects retention in Option B+ prevention of mother-to-child transmission services at antenatal care in Zomba District, Malawi. J Int AIDS Soc. 2016;19. doi: 10.7448/IAS.19.1.20672 26976377

36. Knettel BA, Cichowitz C, Ngocho JS, Knippler ET, Chumba LN, Mmbaga BT, et al. Retention in HIV Care During Pregnancy and the Postpartum Period in the Option B+ Era: Systematic Review and Meta-Analysis of Studies in Africa. J Acquir Immune Defic Syndr. 2018;77: 12.

37. Flax VL, Hamela G, Mofolo I, Hosseinipour MC, Hoffman IF, Maman S. Factors influencing postnatal Option B+ participation and breastfeeding duration among HIV-positive women in Lilongwe District, Malawi: A qualitative study. Blackard J, editor. PLOS ONE. 2017;12: e0175590. doi: 10.1371/journal.pone.0175590 28410374

38. McMahon SA, Kennedy CE, Winch PJ, Kombe M, Killewo J, Kilewo C. Stigma, Facility Constraints, and Personal Disbelief: Why Women Disengage from HIV Care During and After Pregnancy in Morogoro Region, Tanzania. AIDS Behav. 2017;21: 317–329. doi: 10.1007/s10461-016-1505-8 27535755

39. Nhassengo P, Cataldo F, Magaço A, Hoffman RM, Nerua L, Saide M, et al. Barriers and facilitators to the uptake of Test and Treat in Mozambique: A qualitative study on patient and provider perceptions. Garcia J, editor. PLOS ONE. 2018;13: e0205919. doi: 10.1371/journal.pone.0205919 30586354

40. McKinney O, Modeste NN, Lee JW, Gleason PC, Maynard-Tucker G. Determinants of Antiretroviral Therapy Adherence among Women in Southern Malawi: Healthcare Providers’ Perspectives. AIDS Res Treat. 2014;2014: 1–9. doi: 10.1155/2014/489370 25610641

41. Katirayi L, Chadambuka A, Muchedzi A, Ahimbisibwe A, Musarandega R, Woelk G, et al. Echoes of old HIV paradigms: reassessing the problem of engaging men in HIV testing and treatment through women’s perspectives. Reprod Health. 2017;14. doi: 10.1186/s12978-017-0387-1 28982365

42. Hauser BM, Miller WC, Tweya H, Speight C, Mtande T, Phiri S, et al. Assessing Option B+ retention and infant follow-up in Lilongwe, Malawi. Int J STD AIDS. 2018;29: 185–194. doi: 10.1177/0956462417721658 28750577

43. Rosenberg NE, Gross R, Mtande T, Maman S, Golin CE, Saidi F, et al. “We have heard it together”: a qualitative analysis of couple HIV testing and counselling recruitment in Malawi’s Option B+ programme. Afr J AIDS Res. 2017;16: 215–223. doi: 10.2989/16085906.2017.1362017 28978289

44. Manda-Taylor L, Mwale D, Phiri T, Walsh A, Matthews A, Brugha R, et al. Changing times? Gender roles and relationships in maternal, newborn and child health in Malawi. BMC Pregnancy Childbirth. 2017;17. doi: 10.1186/s12884-017-1523-1 28946847

45. Musoke P, Hatcher A, Rogers AJ, Achiro L, Bukusi E, Darbes L, et al. Men’s hopes, fears and challenges in engagement in perinatal health and the prevention of mother-to-child transmission of HIV in rural Kenya. Cult Health Sex. 2018;20: 1259–1272. doi: 10.1080/13691058.2018.1426785 29465291

46. Manjate Cuco RM, Munguambe K, Bique Osman N, Degomme O, Temmerman M, Sidat MM. Male partners’ involvement in prevention of mother-to-child HIV transmission in sub-Saharan Africa: A systematic review. SAHARA-J J Soc Asp HIVAIDS. 2015;12: 87–105. doi: 10.1080/17290376.2015.1123643 26726756

47. Machira K, Palamuleni M. Women’s perspectives on quality of maternal health care services in Malawi. Int J Womens Health. 2018;Volume 10: 25–34. doi: 10.2147/IJWH.S144426 29386917

48. MALAWI GENDER EQUALITY FACT SHEET | Fact Sheet | Malawi | U.S. Agency for International Development [Internet]. 26 Sep 2016 [cited 8 Feb 2019]. Available: https://www.usaid.gov/malawi/fact-sheets/malawi-gender-equality-fact-sheet

49. Flick RJ, Simon KR, Nyirenda R, Namachapa K, Hosseinipour MC, Schooley A, et al. The HIV diagnostic assistant: early findings from a novel HIV testing cadre in Malawi. AIDS. 2019;33: 1215–1224. doi: 10.1097/QAD.0000000000002159 31045942


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2019 Číslo 9
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