PAPER: Community-based approaches for prevention of mother to child transmission in resource-poor settings: a socio ecological review

Community-based approaches for prevention of mother to child transmission in resource-poor settings: a socio ecological review

Ref: Busza, J., Walker, D., Hairston, A., Gable, A., Pitter, C., Lee, S., ... & Mpofu, D. (2012). Community‐based approaches for prevention of mother to child transmission in resource‐poor settings: a social ecological review. Journal of the International AIDS Society, 15, 17373.

My Summary

1) three main categories: Individual, peer and family, community and sociocultural ; Some barriers of pregnant women with HIV to access PMTCT, a social ecological framework: (Buzna, 2012) risk perception , women in married status might think they are low risk of HIV, therefore they are reluctant to access PMTCT. Moreover, fear of receiving a  positive result of HIV also another obstacle to access PMTCT
1) unhealthy condition, mental and physical also affect care seeking to PMTCT
2) Male dominance of female decision in taking decision not enroll PMTCT, not to take HIV result after testing. Female also dealt with fearing partner disapproval and threats of intimate partner violence ti access PMTCT. Moreover, in scarce resources, women’s health is not prioritized.
3) Disclosure of HIV status among pregnant women is associated with accessing health service. Disclosure to partners is associated with infant feeding recommendation
4) Lack of social support, particularly from husband/partner and other family member
5) Stigma is associated with less access of PMTCT and neglection of taking ARV medicine
6) Social network is a way to enhance the full treatment
7) Health and religious beliefs improve the trust and willingness to access PMTCT
8) Policy environment

2) CONTEXT: RESOURCE-POOR SETTINGS, A SOCIAL ECOLOGICAL REVIEW FOR PMTCT SERVICE;

1.     Abstract

Introduction

Numerous barriers to optimal uptake of prevention of mother to child transmission (PMTCT) services occur at community level (i.e., outside the healthcare setting). To achieve elimination of paediatric HIV, therefore, interventions must also work within communities to address these barriers and increase service use and need to be informed by evidence. This paper reviews community‐based approaches that have been used in resource‐limited settings to increase rates of PMTCT enrolment, retention in care and successful treatment outcomes. It aims to identify which interventions work, why they may do so and what knowledge gaps remain.

Methods

First, we identified barriers to PMTCT that originate outside the health system. These were used to construct a social ecological framework categorizing barriers to PMTCT into the following levels of influence: individual, peer and family, community and sociocultural. We then used this conceptual framework to guide a review of the literature on community‐based approaches, defined as interventions delivered outside of formal health settings, with the goal of increasing uptake, retention, adherence and positive psychosocial outcomes in PMTCT programmes in resource‐poor countries.

Results

Our review found evidence of effectiveness of strategies targeting individuals and peer/family levels (e.g., providing household HIV testing and training peer counsellors to support exclusive breastfeeding) and at community level (e.g., participatory women's groups and home‐based care to support adherence and retention). Evidence is more limited for complex interventions combining multiple strategies across different ecological levels. There is often little information describing implementation; and approaches such as “community mobilization” remain poorly defined.

Conclusions

Evidence from existing community approaches can be adapted for use in planning PMTCT. However, for successful replication of evidence‐based interventions to occur, comprehensive process evaluations are needed to elucidate the pathways through which specific interventions achieve desired PMTCT outcomes. A social ecological framework can help analyze the complex interplay of facilitators and barriers to PMTCT service uptake in each context, thus helping to inform selection of locally relevant community‐based interventions.

2.     The Goal The goal was to identify which interventions work, why they may do so and what knowledge gaps remain, focussing on the following four priority outcomes within the EGPAF Community Initiative:

1.     Increased uptake of HIV care and treatment services among pregnant women and vertically infected children;

2.     Improved retention of individuals enrolled in prevention for vertical transmission and care and treatment programmes;

3.     Enhanced adherence of pregnant and lactating women, their partners and children to ARV prophylaxis and/or antiretroviral treatment (ART) and/or other care regimens;

4.    Strengthened psychosocial wellbeing of pregnant and lactating women and children enrolled in care and treatment programmes.

3.     Problematics at each stage of PMTCT to reflect WHO programmatic guidelines

4.     Socio ecological framework for determinants of uptake, adherence and retention in PMTCT

Buzna et al. (2012) explain an individual’s community context may include individual social networks, quality of health services, and social stigma against women living with HIV; and the individual social cultural context may include one’s religious practice and customary gender norms which individually or combined could affect women’s decision on accessing or not PMTCT services

 

Some barriers of pregnant women with HIV to access PMTCT, a social ecological framework: (Buzna, 2012) risk perception , women in married status might think they are low risk of HIV, therefore they are reluctant to access PMTCT. Moreover, fear of receiving a  positive result of HIV also another obstacle to access PMTCT

1) unhealthy condition, mental and physical also affect care seeking to PMTCT
2) Male dominance of female decision in taking decision not enroll PMTCT, not to take HIV result after testing. Female also dealt with fearing partner disapproval and threats of intimate partner violence ti access PMTCT. Moreover, in scarce resources, women’s health is not prioritized.
3) Disclosure of HIV status among pregnant women is associated with accessing health service. Disclosure to partners is associated with infant feeding recommendation
4) Lack of social support, particularly from husband/partner and other family member
5) Stigma is associated with less access of PMTCT and neglection of taking ARV medicine
6) Social network is a way to enhance the full treatment
7) Health and religious beliefs improve the trust and willingness to access PMTCT

8) Policy environment 

The identified barriers are as follows:

Risk perception: While HIV-related knowledge is now widespread, individuals need to perceive themselves to be at risk to seek HCT. Widespread association of HIV with promiscuity and illicit sex (i.e., with sex workers or extramarital partners) creates a false sense of security for some.
Women in monogamous marriages, for example, may consider themselves at low risk [10] and may not present for testing early enough in a pregnancy for optimal initiation of PMTCT.

Self-efficacy to undergo testing, particularly if they need to make complicated logistical arrangements or explain their absence from home. Fear of receiving a positive result has been found to be a disincentive to HIV testing during pregnancy [11].

Health status: Poor mental and physical health also affect care-seeking. Depression has been linked to lower ARV adherence [12,13] while episodes of ill-health compromise ability to maintain appointments [14].

Family relationships: Household inequities in access to resources can mean women rely on others to decide whether or not they initiate PMTCT [15,16]. Male partners play a significant role; some women refuse HCT or do not collect their results, fearing partner disapproval [2,17]. Threats of
intimate partner violence (IPV) also reduce enrolment in PMTCT [18] and studies have shown that women living with HIV can experience higher levels of IPV than others [19]. Where male partners are involved in HIV testing and antenatal care, on the other hand, women are statistically more likely to accept ARV prophylaxis [20_22], deliver in a facility [23] and attend follow-up care [24].

Disclosure of HIV status: Pregnant women’s disclosure to partners is positively associated with service use, while those who keep their status secret find it challenging to store and
take medications [25]. Disclosure to partners also makes it more likely that HIV-positive mothers will follow infant feeding recommendations [26].

Social support: Anticipating and receiving social support proves important for programme retention and is associated with drug adherence [27,28], while pressure from family members, particularly mothers and mothers-in-law, discourages HIV-positive women from departing from traditional
breastfeeding and weaning patterns [29,30].

Travel: Distance to facilities and cost of transportationaffect testing, collection of results and health-seeking behaviours [31].

HIV stigma: A five-country comparative study found a statistically significant relationship between perceived stigma and neglecting to take all prescribed pills [32]. Several other reviews of barriers to treatment [27,33,34] confirm the importance of anticipated stigma, as well as perceptions of
poor service quality (i.e., unfriendly staff, long waiting times
and fear of stock-outs).

Social networks: Qualitative studies examining adherence in Botswana and Tanzania found that, when clients do not have strong social networks in the community, motivation to
remain in treatment is reduced [35,36].

Health and religious beliefs: Prevailing norms and traditional world views shape how people engage with services. If HIV is believed to result from bewitchment or spiritual forces, alternative treatments may be sought [37,38].

Traditions related to pregnancy care, delivery and breastfeeding interact with advice received from health professionals, affecting willingness to comply with PMTCT
requirements [39_41].

Gender roles: Accepted power dynamics between men and women determine how scarce resources are allocated and often do not prioritize women’s health. Gender norms also affect male partners’ behaviour, and expectations of male and female responsibilities pose barriers to male involvement
in pregnancy and infant care [42,43].

Policy environment: Provision of social welfare or insurance schemes, health systems’ functioning and a country’s economic and political stability will all affect service use and

health outcomes across the continuum [44,45].


Results: Our review found evidence of effectiveness of strategies targeting individuals and peer/family levels (e.g., providing household HIV testing and training peer counsellors to support exclusive breastfeeding) and at community level (e.g., participatory women’s groups and home-based care to support adherence and retention). Evidence is more limited for complex interventions combining multiple strategies across different ecological levels. There is often little information describing implementation; and approaches such as ‘‘community mobilization’’ remain poorly defined.