Socio-Demographic Characteristics of mothers and HEIs
Among 342 HIV exposed infants included in the study, more than half, 190(55.5%), were from rural residents. The largest proportion, 154(45%), of the mothers were in the age range of 31-40 years, with the mean age of 30.8 (±6.7) years. More than a quarter, 94(27.4%), of the mothers never attended any formal education. The leading religion was Orthodox Christian, 141(41.2%), followed by protestant, 107(31.3%).
The great majority, 295(85.8%), of the mothers were either married or in union and most, 286(83.6%), were not employed in formal governmental, non-governmental or private organizations. About seven in ten, 242(70.8%) had three or less living children. The proportion of the sex of the HEIs is comparable with male accounting, 172(50.3%). (Table 1).
Table 1: Socio-demographic and reproductive characteristics of HEI and their mothers, West Shoa Zone, 2018 (n=342)
Variables
|
Categories
|
Frequency
|
Percentage
|
Place of residence
|
Rural
|
190
|
55.5
|
Urban
|
152
|
44.4
|
Age of the mothers (years)
|
≤20
|
25
|
7.4
|
21-30
|
137
|
40.0
|
31-40
|
154
|
45.0
|
>40
|
26
|
7.6
|
Educational status of the mothers
|
No formal Education
|
94
|
27.4
|
Primary
|
103
|
30.2
|
Secondary or above
|
145
|
42.4
|
Religion of the mothers
|
Orthodox christian
|
151
|
44.2
|
Protestant
|
114
|
33.3
|
Muslim
|
39
|
11.4
|
Catholic
|
22
|
6.4
|
Others*
|
16
|
4.7
|
Marital status
|
Married or in union
|
295
|
85.8
|
Divorced or separated
|
31
|
9.0
|
Widowed
|
10
|
2.9
|
Never married
|
8
|
2.3
|
Occupation of the mothers
|
Not employed in formal organization
|
286
|
83.6
|
Employed in Government or private organization
|
56
|
16.4
|
Number of living children
|
1-3 children
|
242
|
70.8
|
≥4 children
|
100
|
29.2
|
Sex of the HIV exposed infant
|
Male
|
172
|
50.3
|
Female
|
170
|
49.7
|
*Jova, ‘Wakefata’
Maternal and HIV related cares for mothers and the HEIs
Majority, 290(84.8%), of the mothers had attended at least one ANC visit during the pregnancy of the HEI and 296 (86.5%) had given birth in health facility. About nine in ten, 307(89.8%), of the mothers already know their HIV sero-status either during pregnancy or before and few were diagnosed at the time of labor or after. Though majority, 236(60%), of the mothers had disclosed their HIV sero-status to someone (husband, parent, children, siblings, relative or non-relative), significant proportion, 106(40%), never disclosed to anyone. About seven in ten, 246(71.9%) of the HEIs were enrolled in to the care within a month of birth and most, 279(81.6%), had received Neverapine at enrolment. (Table 2)
Table 2: Maternal and HIV related cares among the mothers and HEIs in West Shoa Zone, Ethiopia, 2018 (n = 342)
Variables
|
Categories
|
Frequency
|
Percentage
|
Had at least one ANC visit
|
Yes
|
290
|
84.8
|
No
|
52
|
15.2
|
Place of delivery
|
Health facility
|
296
|
86.5
|
Home
|
46
|
13.5
|
Time to know HIV sero- status
|
Before or during pregnancy
|
307
|
89.8
|
During or after labor
|
35
|
10.2
|
HIV sero-status disclosure to family member
|
Disclosed to at least one member
|
236
|
60.0
|
Not disclosed to any one
|
106
|
40.0
|
Age of HEI Enrolment to care
|
Within a month after birth
|
246
|
71.9
|
After a month of birth
|
96
|
28.1
|
HEI Received Neverapine at enrolment
|
Yes
|
279
|
81.6
|
No
|
63
|
18.4
|
Status of early infant diagnosis
Among the 342 HIV exposed infants tested and enrolled in the study; 200(58.5%) (95%CI: 53.3%, 63.7%) were diagnosed early (tested in the first 6 weeks of birth). Among this, the majority, 175(51.8%) were done in the first one month of birth. The median testing age of the HEIs was 6 weeks with the mean age of 11.2 weeks. Among the tested 342 HEIs, 13(3.8%) were positive, 4 among early diagnosis and 9 among late diagnosis, showing positivity rate of 2% among early diagnosis and 6.3% among late diagnosis. (Figure 3).
Factors associated with early infant diagnosis
The factors that affect early infant diagnosis were assessed mainly by quantitative method and supplemented by qualitative methods. As indicated in the conceptual framework in the figure 2 above, factors related to maternal socio-demography, maternal and HIV related cares, and infant related variables were assessed quantitatively; whereas, maternal behavior and facility related factors were explored qualitatively.
In the bivariate analysis, among the socio-demographic characteristics, place of residence, maternal education, maternal occupation and number of living children had statistically significant association with the time of HEIs diagnosis. Among the maternal and HIV related cares, time of knowing HIV sero-status, sero-status disclosure, ANC use and place of delivery had statistically significant association. Sex of HEIs and receiving Neverapine at enrolment were among the HEIs related variables that had significant association in the bivariate analysis.
However, after adjustment in the multivariable logistic regression analysis, maternal education and number of living children had statistically significant association among the socio-demographic variables. Among the maternal and HEIs related variables, time to know HIV sero-status, sero-status disclosure, ANC use, place of delivery and receiving Nevirapine at enrolment had statistically significant association with the time of HEIs diagnosis.
The HEIs, whose mothers had attended primary education or above were more likely to be tested and diagnosed early as compared with HEIs whose mothers never attended formal education (AOR=2.41; 95%CI: 1.54, 3.28). Mothers who had fewer (1-3) living children were more than four times more likely to have their HEIs get diagnosed early as compared with those having four or more living children (AOR= 4.76, 95%CI: 2.56, 9.09).
Mothers, who had known their HIV sero-status before or during pregnancy were more likely to have their HEIs get diagnosed early as compared with those who had known their status during delivery or after (AOR=6.24, 95%CI: 2.40, 10.08). Similarly, mothers who had disclosed their HIV sero-status to someone (AOR=8.30, 95%CI: 3.30, 20.60) were more likely to have their HEIs get diagnosed early as compared with those who never disclosed to anyone.
Mothers who had attended at least one ANC (AOR=5.32; 95%CI: 2.53, 8.11) and who had given birth at health facility (AOR=62; 95%CI: 3.39, 11.85) were more likely to have their HEIs get diagnosed early as compared with those having no ANC visit at all and had given birth at home, respectively. Those HEIs who received Neverapine at enrolment were about six times more likely to get diagnosed early as compare with those who didn’t receive (AOR=6.05; 95%CI: 2.48, 14.73) (Table 3).
Table 3. Factors associated with early infant diagnosis among HEIs in West Shoa Zone, Ethiopia, 2018 (n=342)
Variables
|
Categories
|
Diagnosis status
|
Crude
OR (95%CI)
|
Adjusted
OR (95%CI)
|
Early diagnosis
n(%)
|
Late diagnosis n(%)
|
Place of residence
|
Urban
|
103(67.7)
|
49(32.3)
|
1.00
|
1.00
|
Rural
|
97(51.0)
|
93(49.0)
|
0.50(0.32, 0.77)
|
0.83(0.44, 1.22)
|
Educational status of mother
|
No Formal Education
|
37(39.3)
|
57(60.7)
|
1.00
|
1.00
|
Primary or
above
|
163(65.7)
|
85(34.3)
|
3.00(1.81, 4.83)
|
2.41(1.54, 3.28)
|
Occupation of mother
|
Not employed in formal sector
|
158(55.3)
|
128(44.7)
|
1.00
|
|
Employed in formal sector
|
42(75.0)
|
14(25.0)
|
2.43(1.27, 4.65)
|
1.84(0.74, 2.94)
|
Number of living
Children
|
less than four
|
170(70.3)
|
72(29.7)
|
1.00
|
1.00
|
≥4
|
30(30.0)
|
70(70.0)
|
0.18 (0.11, 0.30)
|
0.21(0.11, 0.39)
|
Sex of the infant
|
Male
|
87(50.6)
|
85(49.4)
|
1.00
|
1.00
|
Female
|
113(66.5)
|
57(33.5)
|
1.94(1.25, 3.00)
|
1.23 (0.57, 1.89)
|
Time to know sero- status
|
During or after labor
|
6(17.1)
|
29(82.9)
|
1.00
|
|
Before or during pregnancy
|
194(63.2)
|
113(36.8)
|
8.30(3.30, 20.60)
|
6.24(2.40, 10.08)
|
HIV status
disclosure
|
Not disclosed
|
25(23.6)
|
81(76.4)
|
1.00
|
1.00
|
Disclosed
|
175(74.2)
|
61(25.8)
|
9.30(5.45, 15.87)
|
6.28(3.42, 11.57)
|
At least one ANC visit
|
No
|
12(23.1)
|
40(76.9)
|
1.00
|
1.00
|
Yes
|
188(64.8)
|
102(35.2)
|
8.10(3.60, 18.00)
|
5.32(2.53, 8.11)
|
Place of delivery
|
Home
|
6(13.0)
|
40(87.0)
|
1.00
|
|
Health facility
|
194(65.5)
|
102(34.5)
|
12.70(5.20, 30.90)
|
7.62(3.39, 11.85)
|
Infant Received Neverapine
|
No
|
10(15.8)
|
53(84.2)
|
1.00
|
1.00
|
Yes
|
190(68.2)
|
89(31.8)
|
11.30(5.50, 23.20)
|
6.05(2.48,14.73)
|
Qualitative findings
As barriers to early diagnosis of HEIs, the qualitative methods identified the following themes: low awareness of mothers, fear of stigma and discrimination, distance from facility, shortage of trained health care workers, DBS shortage at facility, delay in sample transportation and reagent shortage at regional laboratories.
Most of the key informants (6 of the 9 mothers and 5 of the 9 health care workers interviewed) reported that most mothers do not know the importance of early diagnosis of HEIs. As a result, most do not bring their infants timely, some even do not show up at all and they bring when the infant gets sick.
A 34 years old mother who brought her HEI to one of the health centers said,
“…I had given birth at this health center and the health worker had told me to bring the infant in two months so that the drug he used to take has to be changed to another drug. But, I was not aware about the test to know his status of HIV infection. Now, the infant is about four months old and I brought him to take syrups as he got sick. I don’t know but, the health worker took blood from my baby’s leg and told me the sample will be sent to far town for test…”
A health worker providing care for the HEIs at one of the health centers also explained,
“…We have been telling to all HIV positive mothers to bring their babies at six weeks to take DBS sample to know the infant’s HIV infection status starting from ANC visit; but, most of them do not take the information carefully and do not bring timely and some do not show up at all. As a result, we don’t lose only infants but also we lose mothers from the treatment and care...”
Most (13) of the key informants (7 of the 9 mothers and 6 of the 9 health care workers) also responded that most mothers of HEIs do not bring their infants to the facility even for immunization, unless the infant gets sick, with the fear that their HIV status will be disclosed to others that may lead to stigma and discrimination as well as conflict from husbands.
A 28 years old mother who brought her HEI to one of the hospitals responded as,
“.. Most mothers do not come alone when they bring their child to health facility for care or immunization. If the person who came with them doesn’t know their HIV status, they do not bring the baby to HEI’s clinic for test, rather they simply go back home...”
Another 36 years old mother added,
“… Mothers whose sero-status is not known by family members usually do not come again to the facility after giving birth with the fear that the infant may be HIV positive and their husband may have a conflict with them, including divorce…”
A health worker working at HEIs clinic of one of the hospitals supplemented by saying, “…Some mothers of HEIs come to our hospital after six months or latter of delivery when they or their infants get sick. When we ask them, they usually tell us that they fear the results may be told to anyone else, including their husbands. I know one mother, who came to this hospital after she became bed ridden and the infant got very sick. When we test, the infant was HIV positive….”
Distance from health facility was also reported as one of the barriers to early diagnosis of HEIs by some of the key informants.
A health worker working at one of the health centers explained,
“…Some mothers, who know that they are HIV positive, do not use the nearby health facility for HIV related cares and hence travel far distances to reach other health facility, where they are not known. Once, they give birth; they usually don’t bring their infants to the facility for test timely because of the long distance and transportation problems….”
About half, 5 of the 9 health care workers and 4 of the 9 mothers included as key informants, reported shortage of trained health care workers and shortage of DBS kits for sample collection to be sent to regional laboratory for the early diagnosis of HEIs, particularly at the health center level.
A health care worker working on ANC and HEIs care at one of the health centers explained,
“…I work alone in ANC room and HEIs care as there is no one else trained on DBS sample collection other than me. The ANC follow up clients’ flow is very high in this Health Center and it is very difficult for me to serve HEIs care additionally, it would be better if HEIs clinic is in a separate room…”
Another female Nurse health care worker from other Health centre supplemented,
“…I haven’t received any special training on HEIs care, particularly DBS sample collection. But, as there was no other trained health care worker, I had been giving care for HEIs including DBS sample collection and sending it to regional laboratory…”
She continued saying,
“…In addition to shortage of trained health worker, we don’t have any DBS kits at all in the last one year in our health centre. We repeatedly reported to Woreda Health Office and Zonal Health Department; but, haven’t received yet. When mothers bring their HEIs for test, we used to tell them to bring another time or to come at 18 months and get tested by antibody test…”
One mother key informant added,
“…Based on the information I received during delivery, I have been bringing my baby to the health centre repeatedly and asking them to test her; but they have been telling me that no sample collecting kit and no trained health care worker to take the sample. This is my third visit and they took the sample today when my baby is about six months old. But, they haven’t told me the result and told me to come again when called when the result is ready .....”
The two key informants interviewed from the regional laboratories reported that delay in DBS sample transportation by postal service, reagent shortage and work load at the regional laboratories were the major reasons for the delay in knowing the results of the HEIs.
A laboratory technologist in one of the regional laboratories explained,
“…We call it early diagnosis of HEIs when the sample is collected before six weeks of age and the result is known immediately. But, sometimes it takes more than a month for the sample to reach at this laboratory through postal service transported by non-medical stuffs using public transport. Besides, one reagent is used for 48 or 96 tests. Because of this, sometimes we are enforced to wait until the sample reaches this number. The other reason is work load, it takes 12 hours to process and finish the test; but there is only one professional assigned on the machine…”